Growing value from Social Determinants of Health

4 months ago

Huge cost and quality improvements are possible by integrating Social Determinants of Health (SDOH) into medical care. Achieving this will be possible when we embrace management methods aligned with the reality of healthcare as a Complex Adaptive System (CAS) explained earlier in this series. This article is about two important concepts.
  

  1. The solution must come from the perspective of the whole, not the parts. 
  2. Alignment of purpose and effort must focus on individual patients, not the population. 

Community health is more than medical care 

Medical services cannot deliver best and affordable care alone. Tackling such wicked problems needs all community disciplines working together. Those at the point-of-care know this by experience and a growing body of evidence supports that more interconnected approaches dramatically improve care and lower costs. What hinders us, then?   We’ve created a delivery system that has broken the community into parts where each works to improve itself in near isolation. 

Take for example, a person living in an impoverished neighborhood. A social service agency may be working to improve neighborhood dysfunction and social networks. At the same time, medical services with patients in the neighborhood, will be trying to improve physical health without a clear appreciation of each patient’s situational reality. Even if recognized, a medical practitioner has few real options to create social change. These disconnects are important because each part of this community – the patient, the social service provider, the medical practitioner, and other agents -  continually self-organize and adapt in response to local situations. Today’s parts based management cannot adapt in time because it doesn’t work from the perspective of the whole. 

It is tempting, but unrealistic to directly integrate medical and social services because they are fundamentally different disciplines. Social services have less of the hard science needed by medicine and the medical model doesn’t include qualitative social dynamics. Moreover, simply putting a social worker in a medical clinic as a liaison is inadequate to create sustainable collaboration around common problems because there is no shared responsibility and no systems level change for either discipline. So how can we successfully integrate the purpose and effort of different disciplines? 

A community must align around individuals, not a population. 


Statistical populations exclude messy interdependency, self-organization, variable clustering, and the propagation of ideas and pathogens endemic in a real-world community. A community is like an elementary school classroom --- a few outliers change the whole. 

The “normal” distribution or bell curve we typically use, assumes that variation is random and evenly distributed. This assumption underlies prediction and best practices. But anyone who follows the weather forecasts, knows prediction has it limits when applied to a natural system. That is because variation within most natural systems is not random at all. 

Natural systems like biology and social networks are messy and inherently unpredictable. Here variation is driven by response and adaptation to events or circumstances. These propagate within the system through the interdependency that a statistical population doesn’t have. Each propagation can create multiple new adaptations. And each new adaptation can be buffered and die out, change its nature, or be amplified to a level not expected. It all depends on the state of the system when each change was introduced, which is unknowable, and that makes these problems unsolvable. Further, change can come from anywhere at any time because in nature, everything touches everything in some way. We need to adapt our game to match the problem. 

Recognizing that this kind of variation is also beneficial is a first step. It is part of nature, and how natural systems like healthcare, work; they are adaptive and generative. Today’s healthcare management model is trapped in a narrative that holds we must limit variation to satisfy a misguided goal of industrial efficiency, instead of maximizing the productivity of a healthy community using our ability to adapt. This begins by focusing on outlier conditions and pain points that drive negative adaptation at the point where medical and social services align; the individual patient. We carry out change by empowering each practitioner at the point of care with more and better options to achieve shared goals each patient. 

Figure 1

Managing community health as a Complex Adaptive System is different. Instead of retrospective analytics, we put power in the hands of those at the point of care and use real-time instrumentation to manage and adapt in step with the community. Both social and medical systems will work better when they create synergy that results from connecting to the underlying reality. 

Next, we’ll look at what social and medical collaboration looks like.