Determining Health

COVID-19 has destabilized our world. People are more stressed, anxious, depressed, and simply tired than ever before. I know that we will see the impact of this on increased rates of alcohol use, drug use, and suicide rates as time goes on.

We need our health care system to be able to handle this increased need – to be comfortable screening all of us for behavioral health needs. If I am feeling extra anxious I need my doctor or a member of her team to ask me and help me figure out the type of treatment that works for me the same way that she checks my blood pressure (which is always too high when I see her because of the aforementioned anxiety).

Giving lip service to ideas but not making any real changes can be worse than doing nothing. All talk and no walk gives people the impression of making progress. This can take away motivation for change. We do not want our Bree Collaborative work to be all talk and no walk. We want to and we must change the how and the what of health care delivery in Washington State.

We have talked a LOT about this increased behavioral health need – and how Bree has set standards for increasing access to behavioral health and is working hard to get these standards into practice across our diverse state through practice transformation and our broader learning community. We also know that so much of our behavioral and physical health needs are driven by the social determinants of health. Much like depression 10 years ago, we know that social determinants matter but that people are reluctant to ask because they don’t know what to do if the answer is yes. We are still pushing for greater screening and interventions around behavioral health and our community is just starting to do this for the social determinants of health too.

About 40% of any one person’s health comes from the social and economic factors around them – your education, whether or not you are employed, the type of job you have, your income, how much support you get from your family and friends, and the safety of your community. We also know that only a very small amount of our overall health is determined by clinical care – some estimate 11–20%. Why does this matter? We spend most of our health care dollars on this 11-20%. Not the most effective use of funds.

The New England Journal of Medicine Catalyst Insights Council argues that Health Care Organizations Can and Must Incorporate Social Determinants. How can we do this? We all worry about whether it is fair to charge a delivery system with the role of intervening in the spaces outside of their control. A primary care clinic cannot control how easy it is to navigate transportation, an individual doctor cannot build housing. BUT we can ask and we can refer people to appropriate services, whether internal or external to our systems.

Franklin County Public Health in the state of Ohio has developed a framework to screen and intervene around the social determinants of health called the Core 5. Our Collaborative was lucky to hear from Alison Bradywood, MN, MPH, RN, NEA-BC with Virginia Mason Medical Center on their work to screen and intervene around social determinants of health at our meeting in May. Virginia Mason reviewed and adapted the evidence-informed set of Core 5 questions developed in Ohio and has used this with some service lines with the intent for spread. It is recommended for these questions to be completed by self-report with privacy provided:

• – Do you/your family worry about whether your food will run out and you won’t be able to get more?
• – Are you worried about losing your house or are you homeless?
• – Are you currently having issues with your utilities such as your heat, electric, natural gas or water?
• – Has a lack of transportation kept you from attending medical appointments or from work, or from getting things you need for daily living?
• – Are you worried that someone may hurt you or your family?
• – (Added by Virginia Mason) Do you currently have concerns about your ability to care for yourself after surgery or are worried you won’t have anyone to help you when you get some?
• – (Added by Virginia Mason) Have you ever skipped medications to save money?

If someone screens positive for these questions, they can be connected with internal resources like social work and financial services and/or external community resources. Asking these type of questions and having a concrete process for next steps will become even more essential as we move through the economic consequences of COVID-19. Our Collaborative looks forward to following this work and thinking about adapting to a primary care setting.

Ginny Weir, MPH
Director, Bree Collaborative