Equality Health Embeds Social Determinants of Health in Care Delivery

Phoenix-based Equality Health gathers social determinant data at primary care practices to connect patients with social services.

Equality Health has included addressing social determinants of health in the health system's care delivery system, with primary care practices playing a leading role.

Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address social determinants and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.

"The model for our delivery of healthcare incorporates social determinants and a cultural approach to care. For us, social determinants are not a standalone project. That is a key element of the success that we have seen so far. It is not a bolt-on program. We are not doing it to be compliant with a government mandate. We are addressing social determinants because we think it is the best way to deliver care and improve outcomes," says Mark Stephan, MD, MBA, chief medical officer of Equality Health.

Including social needs in care delivery

Primary care practices are a foundational element of Equality Health's social determinant efforts, screening patients for social needs and cultural preferences with the health system's Social Cultural Risk Assessment survey. The risk assessment tool queries patient about housing, transportation, food insecurity, cultural beliefs and preferences around healthcare and medications, behavioral health, physical activity, sense of wellbeing, and spiritual needs.

The risk assessment survey, which was developed by Equality Health and has undergone several revisions, is administered to patients while they wait for their primary care appointments.

"It is a brief questionnaire but covers a lot of ground," Stephan says.

Primary care practices were chosen to play a frontline role in the effort to address SDOH because the clinics have relationships with patients, he says. "The doctor's office is still very much a trusted source of care. There is a doctor-patient relationship. It is an effective area to collect a survey from a workflow perspective."

Equality Health's onboarding of new primary care practices features four hours of training, which includes instruction on cultural awareness and SDOH for the entire staff. 

"We go beyond cultural competence in our training to what I call cultural care delivery. There are three levels. One is cultural awareness. Another is cultural competence—being sensitive to how things are presented. Finally, there is cultural care delivery, which means we are expecting there to be cultural preferences in how healthcare is accessed and utilized," Stephan says.

An example of cultural care delivery is accommodating the participation of several family members during primary care visits, which is a cultural preference of many ethnic minority groups.

Related: Social Determinants of Health: Lead or Partner

If a patient screens positive for a social need, clinicians can make referrals to community-based organizations and other local resources. The referrals are managed digitally in a two-step process, he says. First, social needs referrals are entered in Equality Health's care coordination platform with other "wrap-around" services such as patient education counseling. Second, social needs referrals are placed on a social determinants platform that can be accessed by local social services providers.

"The next step is making the social determinants platform available so that a referral done at a practice will go directly into that platform," he says.

Equality Health has curated its network of social service providers, Stephan says. "It is a mix, but the majority are community-based organizations."

The health system engages patients to make sure referrals result in action, he says. "On the surface, you think you just point people in the right direction of a community-based organization and hope for the best. But we reach out to patients digitally and we reach out telephonically."

Primary care practices receive a quarterly financial incentive from Equality Health for administering the Social Cultural Risk Assessment survey, he says. "What we have done is break incentives down into quarterly payments, so that we are closer to real time. It gives more immediate feedback on the activities that doctors have done to earn the incentive."

Addressing healthcare disparities

Tackling SDOH is only part of Equality Health's approach to closing healthcare disparity gaps, Stephan says.

"Socioeconomic status makes a difference in people's ability to access care and to understand the plan of care; but beyond that is the core of our thesis, which is how you perceive the delivery of care and how you perceive the relationship with the clinicians and practices that are delivering care. That matters as much as anything because when it comes down to it, when you are discussing going through a procedure the key to success is the relationship between the clinician and the patient."

Cultural care delivery promotes positive relationships between clinicians and members of minority ethnic groups, he says. "There has to be trust. The more trust and deeper the relationship, the more mutual understanding, and the more likelihood that the care plan will be successful and there will be a better health outcome."

While it is difficult to tease out the impact of social needs referrals and cultural care delivery, Equality Health believes its approach is making a difference for the health system and the communities it serves, Stephan says.

"We know directionally that by incorporating this survey, by doing the training, by deploying our model across our network, we are being successful partnering with health plans and physician practices, and better outcomes are happening. The cost of care is going down and the quality is improving."