Social Determinants of Health: Tackle Disparities From the Pharmacy

Nonmedical issues are requiring pharmacists’ attention in increasingly urgent ways, especially in light of the coronavirus disease 2019 (COVID-19) pandemic. A greater focus on social determinants of health (SDOH) may lead to a much more comprehensive approach to treating patients in the pharmacy and ultimately drive improved outcomes. Overall health is often determined by social and economic issues, and understanding how these factors affect patients is key to identifying and addressing SDOH in the pharmacy setting.

The World Health Organization (WHO) defines SDOH as the conditions in which individuals are born, grow, live, work, and age. The WHO definition also states that these circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. SDOH can be directly related to health inequities contributing to unfair and avoidable differences in health status. However, the health care community is now addressing these issues in a much more formal way, with the COVID-19 pandemic placing even greater urgency on pharmacists to adopt models of SDOH.

Hannah Fish, PharmD, associate director of strategic initiatives at the National Community Pharmacists Association in Washington, DC, said pharmacists are one of the most accessible health care providers and are often the first point of care for many patients. “Pharmacists are intimately familiar with the lives of the patients in their community and often are aware of nonmedical-related concerns such as transportation, housing, and food security," she told Drug Topics®.

Fish added that because many independent pharmacies deliver medications, they can see firsthand many of the SDOH affecting their patients. Pharmacies across the country are starting to train their pharmacy technicians as community health workers. “Pharmacists have been leveraged informally as the eyes and ears of the care team, documenting what they see in their pharmacy management systems or simply just knowing their community so well. Now we’re starting to see some formality,” she said.

The CDC has recognized the importance of SDOH to public health and has established programs that partner with communities to provide a greater health impact. The CDC programs include the National Program to Eliminate Diabetes-Related Disparities in Vulnerable Populations, which helps 6 organizations plan, develop, implement, and evaluate multisector, community-based interventions.

Fish said some community health workers can assist with screening and assessing patients adversely affected by SDOH. These health workers can serve as a referral source to connect patients with the resources they need, such as food banking services, transportation services, and more. “A pharmacy might have helped a patient with finding these resources in the past, [and] community health workers are able to expand and expedite this service,” said Fish.

Richard Logan Jr, PharmD, Logan & Seiler, Inc L&S Pharmacy, Medical Arts Pharmacy, Charleston, Missouri, echoed Fish’s recognition of the pharmacist’s role in patient’s health care: “This relationship has been for years the cornerstone of clinical pharmacy services. From addressing access to medications for reasons clinical or financial to acting as a triage and referral site into the health care system, no one spends more eyeball-to-eyeball time with the patient than their pharmacist,” he said.

Logan noted that the best health care system in the world is of no use to a patient who cannot access it. If an individual has an appointment with a physician but has no way to get to the office, that appointment is pointless. “People who have poor access to food are worrying about their next meal, not their [high-density lipoprotein] levels,” said Logan. SDOH in various forms can create a significant barrier to health care. “[The Centers for Medicare & Medicaid Services] has recognized this and legitimized it with a whole series of ICD-10 [International Classification of Diseases, Tenth Revision] codes addressing SDOH as a barrier to care," said Logan.

A patient with a chronic disease usually has 35 or more visits to a pharmacy in a year, making the pharmacy the logical “go-to place” to delve into how SDOH are affecting a patient’s care, according to Logan. Often the pharmacy is the canary in a coal mine for patient access to health care. “We see patient struggles first, either through conversations in the pharmacy or when we deliver to their home and step into their lives. In our practice, and others of which I’m aware, we employ trained community health workers to interact with patients, interview patients, refer patients to services, and assist them in any way possible to address their SDOH [and] access to care in a caring, compassionate, effective way,” said Logan. Logan said by focusing on SDOH, his group has had great success, in both positive patient outcomes and increased professional awareness among local health care colleagues.

Lack of Awareness

Linn Gould, MPH, executive director of Just Health Action in Seattle, Washington, said the term SDOH has existed for more than 20 years. Yet many pharmacists have never even heard of it. “From 2001 to 2003, the jargon started being adopted more widely. So it is fascinating that there are so many people who have never heard of it,” said Gould.

Medical and pharmacy schools appear to be failing in addressing SDOH. One recent article suggested that major structural and cultural transformations in medical education are warranted to address social and economic issues. The authors wrote that educators need to discuss not only poverty but also oppression, racism, sexism, and homophobia. One local pharmacist in Seattle told Drug Topics® that he had never heard much about SDOH. He said he is surprised by how little attention SDOH receive and that most pharmacists have a total lack of awareness of SDOH. Yet most pharmacists would probably adopt a model if they had the knowledge and were given the opportunity, he added. Unfortunately, the current operational model for retail pharmacies is now extremely transactional and, for the most part, does not allow pharmacists to take into account SDOH.

COVID-19 Effects Change

Currently, the COVID-19 pandemic is requiring that pharmacies address SDOH in many areas. Mass unemployment, for instance, has led to myriad new needs. “Pharmacies delivering medications are calling their patients to see whether they need anything else, such as groceries, before going to the home,” said Fish. She said during the current period of social distancing, calling patients once a week to check on their general well-being and mental health may be appropriate. “In addition to employing community health workers, we’ve seen pharmacies partner with local farmers’ markets to provide fresh produce for patients coming to the pharmacy. Further, insurers are recognizing the impact SDOH have on health outcomes and are expressing a desire to work with pharmacies to address these concerns,” said Fish.

Logan said pharmacists are rising to meet the challenge of remote patient care via enhanced deliveries, curbside services, expanded personal patient outreach, and an increase in those patient touch points even as patients shelter in place. Many older patients in particular are now unable to make physician visits, putting them at risk of uncontrolled chronic comorbidities. “Our pharmacies are checking in regularly with our patients with chronic conditions to make sure they are not ignoring other conditions for the sake of COVID-19,” Logan told Drug Topics®.

Gould works in Seattle’s Duwamish Valley, a community with environmental justice concerns as a result of significant air pollution problems. “It has one of the highest childhood asthma hospitalization rates in the city of Seattle, and now we have evidence that the higher air pollution [is], the higher the COVID-19 death rate [is]. We have also learned that there is a link between asthma and COVID-19 rates," said Gould.

The physical distancing measures required to slow the spread of COVID-19 are substantially more difficult for those with adverse social determinants. According to Denise Fu, PharmD, clinical programs manager in Patient Care Services at Johns Hopkins Home Care Group Pharmacy Services in Baltimore, Maryland, although many pharmacists can identify SDOH issues, they need more education regarding available resources to help them address the barriers. “For example, pharmacists may be able to assist the patient with access to prescription medication but would need to refer the patient to other resources for employment, food insecurity, or housing instability,” she said.

Fu also said that improving information technology can help by filling in the gaps with SDOH data. One published study suggested that a lack of policy standards around SDOH data may be hindering adoption. However, commercial vendors are interested in collaboratively discussing policy solutions such as standards and guidelines. The investigators evaluated the development of electronic health record (EHR) software products that allow health care providers to identify and address patients’ SDOH. They conducted interviews with 6 EHR vendors with large market shares in both ambulatory and inpatient settings. The study results showed that SDOH appear to be an area for growth and that vendors offer a wide range of SDOH-related products with various levels of sophistication.

“If health care providers are able to collect and document SDOH risk factors, technology can help by seeing how many and to what extent of the 5 SDOH domains a particular patient is experiencing. If a patient is unable to keep the water on in their house or food on the table for their family, they are most likely not going to be able to afford and take their medicines,” said Fu.

A century ago, helping individuals with SDOH made a significant impact against tuberculosis, another highly infectious disease. At that time, better housing, a reduction in overcrowding, and improved nutrition saved countless lives. Now pharmacy is stepping up to formally address SDOH to help lower both morbidity and mortality during the current pandemic and beyond.