M&D Clinical Corner: Community Pharmacist’s Guide to Social Determinants of Health

The Clinical Corner is a monthly feature that highlights a variety of important pharmacist topics that is written by Morris & Dickson’s staff pharmacist, Paula Belle (RPh).

This month’s Clinical Corner will discuss social determinants of health (SDoH).

• What are Social Determinants of Health (SDoH)
• The Pharmacist’s Role in Confronting SDoH
• Community Pharmacy Practice Models That Address SDoH
• Pharmacy Reimbursement for SDoH Screenings and Referals
• Resources for Pharmacists

What Are The Social Determinants of Health?

• Social determinants of health (SDoH) are the nonmedical factors that influence health outcomes. [1]
• SDoH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. [2]
• SDoH have become a prominent buzz word in the health care industry over the past few years. [3]
• This is because conditions in which people live, learn, work, and play can affect their health risks and outcomes, making SDoH an important component in understanding patient health outcomes. [3]

SDoH can be categorized into 5 domains [2]:

• Economic stability
• Education access and quality
• Healthcare access and quality
• Neighborhood and built environment
• Social and community context

Social determinants of health (SDoH) have a major impact on people’s health, well-being, and quality of life.

Examples of SDoH include [2]:

• Safe housing, transportation, and neighborhoods
• Racism, discrimination, and violence
• Education, job opportunities, and income
• Access to nutritious foods and physical activity opportunities
• Polluted air and water
• Language and literacy skills

SDoH also contribute to wide health disparities and inequities. [2]

• For example, people who don’t have access to grocery stores with healthy foods are less likely to have good nutrition. [2]
• This raises their risk of health conditions like heart disease, diabetes, and obesity and even lowers life expectancy relative to people who do have access to healthy foods. [2]

The Pharmacist’s Role

• Social factors play an integral role in a patient’s overall health, with up to 90% of health outcomes dependent on health-related behaviors and socioeconomic and environmental factors. [4]
• A recent survey of U.S. hospitals and physician practices reported that only 24% of hospitals and 16% of
• physician practices screen for SDoH, specifically regarding the 5 social needs prioritized by the Centers for Medicare & Medicaid Services: food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence. [4]
• Community pharmacies are ideally placed to play a major role in addressing SDoH as they are local and accessible community advocates. [4]
• Pharmacies are one of the most accessible health care providers, with 90% of Americans living within 5 miles of a pharmacy. [4]
• A cross-sectional study of a representative nationwide sample of Medicare beneficiaries showed that patients visited community pharmacies twice as frequently as they visited primary care providers. [4]
• A number of innovative community pharmacy practice models that focus on social issues are currently being explored. [4]
• By being aware of their community’s resources, pharmacists can serve as the bridge between a patient’s cry for help and the help that they need.[5]

Community Pharmacist Practice Models That Address SDoH

Community Health Worker Model

• In this practice model, community health workers (CHWs) are integrated into the community pharmacy setting. [4]
• CHWs serve as frontline public health workers who act as an effective bridge between the communities they serve and the medical establishment. [4]
• Common CHW roles in a pharmacy can include service coordination, informal counseling, health education, care management, and community advocacy. [4]

CHWs may be implemented as an hourly pharmacy staff role by 2 methods [4]:

1. providing support for current motivated pharmacy staff to become trained as CHWs
2. hiring a CHW

• In this model interested pharmacy technicians (or other employees) may complete state-mandated CHW training. [4]
• CHW training and certification vary from state to state, so state-specific policies should be reviewed before implementing such a model. [4]
• The CHW would be responsible for leading the SDoH program at the pharmacy, directing and educating other pharmacy staff members on the identification of patients with SDoH to send to the program. [4]
• In addition, the CHW would be responsible for completing SDoH screening, assessments, referral plans, and follow up.  [4]
• By having the CHW lead the program, this would limit the workflow interruption to other pharmacy staff members. [4]

Development of SDoH Specialists Model

• In this practice model, a SDoH specialist is developed using established pharmacy resources. [4]
• SDoH specialists are members of the pharmacy team trained with substantial knowledge of the 5 SDoH. [4]
• In this model, staff members can be trained to identify, screen, and assess patients for social-related issues. [4]
• These SDoH specialists use this knowledge to connect pharmacy patients to community-specific resources and advocate on behalf of patients in at-risk populations. [4]
• An SDoH specialist’s role in a pharmacy is to lead the SDoH program, directing and educating other pharmacy staff members on how to identify and screen patients for SDoH. [4]
• The SDoH specialist takes the identification and screening information to assess patients for opportunities for intervention, implements a patient-specific plan, refers the patient to community-specific resources, and follows up to ensure that the patient attained and maintained access to these services, augmenting the patient plan as necessary. [4]
• Many pharmacies already have staff members likely to succeed in this role, making the development of this new staff model more efficient for pharmacies while also generating new business and improving patient care. [4]
• The design of the SDoH specialist role is intended to be hourly, integrating the role’s responsibilities into the pharmacy’s workflow. [4]

Pharmacy Reimbursement for SDoH Screenings and Referrals

• Examples of funded SDoH pilot programs for community pharmacies include programs with CPESN-Missouri and CPESN New York. [4]
• These pilot programs represent novel approaches to integrating community pharmacies and local organizations to address social-related issues; nevertheless, these programs are primarily supported by grant funding or performance incentive contracts. [4]
• An important contributor to the expansion and sustainability of such programs will be their incorporation into a traditional or value-based reimbursement model. [4]

CPESN-Missouri SDoH Pilot Details [4] :

• This pilot employed the CHW model with interested pharmacy technicians completing state- mandated CHW training.
• All other pharmacy staff members completed in-house and National Community Pharmacists Association (NCPA) training modules.
• CHW-trained technicians led the program, but all staff were trained in identifying and screening patients for social-related issues.
• The pharmacies collaborated with the Missouri Department of Health and local community organizations.
• A resource notebook was created that included information on local and accessible resources that address SDoH.

Funding sources

1. Centers for Disease Control and Prevention
2. Health Resources & Services Administration

Workflow details

1. Subjects are screened by the pharmacy’s delivery driver using an SDoH needs assessment tool.
2. The needs assessment tool is dropped off in the pharmacy for review by the CHW.
3. The CHW engages with the subject and performs a comprehensive SDoH assessment.
4. The CHW refers patients for pharmacy services or to a local community organization (e.g., food pantry, loneliness resource).
5. CHW completes follow-up.

Current outcomes of pilot study

1. 1400 delivery driver home assessments
2. 200 CHW referrals
3. Over $87,000 in estimated annual out of pocket prescription savings

CPESN-New York SDoH Pilot Details [4]:

• This model employed the SDoH specialist model with pharmacy staff involved in the program completing in-house training and an NCPA training module.
• For this program, the pharmacies aligned with an Independent Practice Association (IPA) within Albany, NY, a regional organization that focuses on providing community-based social services.
• IPA provided an online technology platform for the pharmacies to input referrals that are then completed by a care coordinator. This IPA takes responsibility for identifying community resources, connecting the patient to those resources, and following up with the patient to determine if they accessed that resource.

Funding sources

1. Performance incentive contract
2. Community Pharmacy Foundation

Workflow details

1. Subjects are identified using the pharmacy database.
2. Pharmacy staff member completes SDoH screening tool.
3. Subjects identified with social related risks are inputted into the IPA online platform.
4. IPA case manager contacts subjects, completes assessment, and refers to a local community organization.
5. Case manager completes follow-up

Current outcomes of pilot study (Oct-Dec 2020)

1. 48 total e-referrals
2. 15 patients denied consent to participate at pharmacy
3. 11 patients accepted referrals
4. 22 patients did not accept IPA’s referral
5. Top 2 referral types were transportation and food assistance (7 referrals each)

Resources for Pharmacists

• An example SDoH assessment questionnaire employed by a pharmacy is available at : https://www.chcs.org/media/Towncrest-Pharmacy-SDOH-Screening-Tool_050619.pdf
• For guidance on designing a customized SDoH assessment see: https://patientengagementhit.com/features/considerations-for-social-determinants-of-health-screening-design
• AN SDoH implementation toolkit is available at: https://communitypharmacyfoundation.org/resources/grant_docs/CPFGrantDoc_9853.pdf
• CPESN USA offers a Special Purpose Network know as Health Equities for pharmacies that are interested in conducting SDoH screening for reimbursement. More information on CPESN Health Equities is available at: https://files.constantcontact.com/62111018601/e8be98b9-6890-40c7-9875-96dfe519f42f.pdf
• A brief video detailing CPESN Health Equity SPN is available at: https://vimeo.com/805798220

Information on training requirements for CHW by state can be found at these links:

1. https://www.astho.org/topic/brief/state-approaches-to-community-health-worker-certification/
2. https://www.ruralhealthinfo.org/toolkits/community-health-workers/4/training/certification

• A list of CHW networks and training programs is located at: https://nachw.org/membership/chw-networks-and-certification-programs/

Sources

• Centers for Disease Control and Prevention. Social Determinants of Health at CDC | About | CDC. 2022 2022-12-12T03:41:29Z [cited 2023; Available from: https://www.cdc.gov/about/sdoh/.
• U.S. Department of Health and Human Services. Social Determinants of Health. [cited 2023; Available from: https://health.gov/healthypeople/priority-areas/social-determinants-health.
• Hippensteele, A. Pharmacists’ Role in Tackling Social Determinants of Health. 2020 [cited 2023; Available from: https://www.pharmacytimes.com/view/pharmacists-role-in-tackling-social-determinants-of-health.
• Foster, A.A., et al., Addressing social determinants of health in community pharmacy: Innovative opportunities and practice models. Journal of the American Pharmacists Association, 2021. 61(5): p. e48-e54.
• Blanche Palasi, P.C.S.J.s.U.C.o.P.H.S.Q., New York Christine Chim, PharmD, BCACP Associate Professor–Industry Professional St. John’s University College of Pharmacy & Health Sciences Queens, New York, Social Determinants of Health and Impact on Marginalized Populations During COVID-19. 2023. 47(8): p. 26-30.