Addressing the Social Determinants of Health within a Primary Care Model:
Survey of Oregon Primary Care Clinics
Cassandra Robinson, MS, LPN
Portland State University
Abstract
Social determinants of health (SDH) are factors other than genetics within our environment
that affect our health such as food, housing, education, employment, and social support.
Previous studies indicate that social circumstances have a larger impact on quality of life
and mortality than our actual physical health. Primary care physicians and clinics can be a
crucial point of contact for many patients needing assistance in one or more of these areas.
By addressing SDH, in addition to biological health concerns, in primary care clinics, many
people may achieve a higher level of overall health. There are a number of pediatric
practices that have adopted a process of screening for psychosocial issues, as it is known
that these factors have a significant impact on childhood development. However, many
adult and pediatric primary care physicians are still lacking the tools they need to address
patient social needs. This survey will look at what the potential perceived physician
barriers are to providing these services to patients. The information collected from the
survey will be used to inform best practices to address SDH in primary care as well as
influence policy regarding funding in these areas.
Addressing the Social Determinants of Health within a Primary Care Model:
Survey of Oregon Primary Care Clinics
Social determinants of Health (SDH) are factors other than genetics within our
environment that affect our health such as food, housing, education, employment, and
social support. For the purposes of this proposal, SDH refers to food, housing,
transportation, and employment. SDH and other health inequities have been shown to have
a more significant impact on population health and life expectancy than health care itself
(Braveman & Egerter, 2013). In fact, unmet social needs account for an estimated 60% of
premature death risk (McGinnis, Williams-Russo, & Knickman, 2002). Providing resources
for people with unmet social needs is imperative to improve the health of the population.
When considering providing the resources, the question arises “how do we best reach
people in need of these services?” The conceptual framework surrounding SDH places the
health system directly between the intermediary determinants of health and impact on
equity in health and well-being (Figure 1).
According to The Institute of Medicine, primary care is the “provision of integrated,
accessible health care services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained partnership with patients,
and practicing in the context of family and community” (Shi, Starfield, Politzer, & Regan,
2002). Primary care providers should then, by definition, have a part in addressing patient
social needs in the context of their community, and not solely managing their immediate
biological health concerns. Physicians in primary care clinics are uniquely positioned to be
a point of contact between the patient (community member) and social resources. Within
the doctor-patient context, a patient is more likely to divulge their unmet social needs to
their physician, especially as it applies to their health (Shi et al., 2002).
Figure 1. Conceptual Framework of the Social Determinants of Health
Source: (Solar & Irwin, 2010)
Though some primary care providers (PCP’s) may understand the link between
health outcomes and SDH, they are left without the necessary tools to address these issues.
In a recent national survey, the Robert Wood Johnson Foundation (RWJF) found that 85%
of providers believe that unmet social needs are directly leading to worse health in their
patients, 82% of physicians feel they are unable to address patients health concerns that
are due to unmet social needs (Goldstein & Holmes, 2011). One innovative model that has
been implemented in the United States to provide the tools that connect patients to
resources is Health Leads (Garg, Marino, Vikani, & Solomon, 2012). As demonstrated in
their model (Figure 2.), Health Leads provides the link between the patient, the physician,
and social programs by allowing physicians to write a prescription for specific services like
housing, transportation, utility assistance, and access to nutritious food. Once written,
these prescriptions are then filled by volunteer staff who provide resources in the form of
human services contact initiation, assistance with completing applications, and follow-up
with the patient to ensure they were able to attain the resources intended.
Figure 2. Health Leads Model
Source: https://healthleadsusa.org/what-we-do/our-model/
‘The introduction of patient-centered medical homes has assisted in bridging the
gap between the patient and physician referrals, often allowing a patient to access other
services with more ease. [I want to link PCPCH to SDH here, but thinking it may need to be
part of an agenda, or a secondary aim]. The Oregon Health Plan is unique to other states in
their patient-centered primary care home model. [More literature/background research
needs to be done for this section]
Research on the primary care physicians’ role in addressing the SDH is largely
unstudied, the 2011 Physicians’ Daily Life Report Aside. It is unknown what is currently
being done in primary care as well as what physicians are willing to do to address these
unmet social needs. When asked if they would be interested in writing prescriptions for
social needs, more than two-thirds of physicians agreed that they would (Goldstein &
Holmes, 2011).
Purpose of the Study
The purpose of this study is to identify the level at which primary care physicians in
Oregon are able and willing to address social determinants of health within their patient
population. It will look at potential tools as well as perceived barriers and obstacles to
addressing SDH within their practice.
The online survey will provide insight into the more frequent unmet social needs of
rural versus urban populations, the impact of recent patient-centered primary care home
(PCPCH) models on SDH, resources available in specific areas, physician knowledge of
resources, their ability to refer and connect patients to those resources, and to a limited
extent, whether a clinic workflow has been established in each practice for community
referrals.
Research Question
Are Oregon primary care providers equipped with the tools necessary to address
areas of unmet social needs (housing, food, employment, and transportation)?
Objectives:
Primary Objective: Determine the overall climate for addressing social determinants of
health (housing, food, employment, and transportation) among Oregon primary care
providers (PCP).
Question #1: What are the barriers perceived by PCP’s to addressing SDH in
primary care?
Question #2: Do physicians avoid asking about social circumstances due to an
inability to provide a solution?
Question #3: What available resources are providers already aware of?
Secondary Objective: Assess the acceptability among PCP’s of potential interventions for
addressing SDH in a primary care setting.
Question #1: Are providers willing to screen patients for unmet social needs?
Question #2: If funding assistance was available, would providers be willing to
implement a new workflow within their practice? If funding is not available?
Question 3: Would providers be comfortable writing “prescriptions” for social
needs?
Hypothesis
The majority of primary care physicians in Oregon will lack the necessary resources
to address SDH, however, physicians who participate in a PCPCH will have fewer barriers
and more tools to address the housing, food, employment, and transportation needs of
their patient population.
Research Design
Primary care providers, inclusive of adult and pediatric practice, in Oregon will be
identified through the Medicare/Medicaid provider directory and invited to participate in
an online survey. A summary of the survey and study purpose will be provided in the
introductory email. Once the invitation with survey link has been sent, providers can access
the survey from any internet-linked computer, tablet, or phone. The survey is designed to
take less than 15 minutes to complete and will request basic clinic/provider/patient
population demographics. Sample Survey Questions are indicated in Appendix I.
Figure 3. Study Design
Clinic/Physician
Selection
• Identify
primary care
providers
within Oregon
Email/Mail
Survey
• Include 1Summary of
Study Purpose
& Survey
Description
Re-Send Survey
• 6-week and 8week
Analysis
• **Have not
determined the
type of
analysis**
References
Braveman, P., & Egerter, S. (2013). Overcoming Obstacles to Health in 2013 and Beyond.
Robert Wood Johnson Foundation. Princeton, NJ.
Garg, A., Marino, M., Vikani, A. R., & Solomon, B. S. (2012). Addressing families’ unmet social
needs within pediatric primary care: the health leads model. Clinical Pediatrics, 51(12),
1191–3.
Goldstein, D., & Holmes, J. (2011). 2011 Physicians’ Daily Life Report. Princeton, NJ.
McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The Case For More Active
Policy Attention To Health Promotion. Health Affairs, 21(2), 78–93.
Shi, L., Starfield, B., Politzer, R., & Regan, J. (2002). Primary Care, Self-rated Health, and
Reductions in Social Disparities in Health. Health Services Research, 529–550.
Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of
health. Social Determinants of Health Discussion Paper 2 (Policy and Practice).
Appendix I. Sample Survey Questions
Basic demographics: Age, years in practice, gender,
What is your main area of practice?
Do you identify your practice as urban, rural, or other? What ZIP code is your practice
located?
Is your medical practice characterized as a patient-centered primary care home?
If so, what tier of PCPCH?
Do you have patients who express that they are unable to purchase nutritious food?
If yes, approximately what percentage of total patient population?
Do you have patients who indicate that they do not have safe and/or proper housing
accommodations?
If yes, approximately what percentage of total patient population?
Do you have patients report that they do not have adequate transportation?
If yes, approximately what percentage of total patient population?
Do you initiate conversation with patients regarding their social needs?
If not, why?
What resources do you utilize, if any, to assist patients to meet transportation,
employment, and nutrition needs?
If you were able to write a prescription for nutrition, employment, and housing resources
for your patients, would you participate this service? If no, why not?
If a patient expresses an unmet social need, what would prevent you from assisting them to
meet that need? Options: Time, resources, patient willingness, other.