NOTE for Physicians: This section provides detailed information for PCN Change Support Staff who will support you to embed SDH in your clinic. Feel free to review it, but don’t worry about the details. Your PCN Practice Coach will work with your clinic to develop an Implementation Plan that addresses your priorities.

 

COMMUNITY

SOCIAL DETERMINANTS OF HEALTH
IN YOUR CLINIC

PCN Practice Coaches, based on clinic interest, capacity and competency, will include these practices in Implementation Plans and  support clinics to achieve them.

1. Focus on populations more likely to be at risk of poor health due to SDH. The SES profile reviewed and the community services researched in the planning stage will prepare the clinic to address the community’s priorities and most pressing needs:

  • Indigenous peoples
  • New immigrants
  • Women
  • LGBTQ+
  • Those from low SES neighbourhoods

2. Recognize disease conditions particularly impacted by SDH:

  • Diabetes
  • COPD
  • Congestive heart failure
  • Mental illness

3. Analyse the clinic’s patient population data to ensure a good understanding of the social determinants affecting them most (e.g. SES, race, immigration status, etc.).

4. Consider co-location with other required services – Co-locating services benefits the patient and provider by improving access to social, legal and other health services, reducing transportation concerns, and increasing patient satisfaction.
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5. Connect with community organizations that could support the clinic’s patients. Begin by focusing on 3-4 key organizations, such as the United Way or YM/YWCA. Invite them to a ‘sharing session’ where you explain the practice’s equity focus and learn more about their services.

6. Access Pathways to find out about specialists and clinics that may support these patients.

7. Advocacy – Work to improve the social and economic circumstances of the community, as a Community Health Champion:

  • Join an advocacy organization such as Health Providers Against Poverty, an alliance of health care providers working to eliminate poverty and reduce health inequities in Canada, or Upstream, aimed at building a healthy society through evidence-based, people-centred ideas.
  • Lend your voice to local health care and social service organizations to provide organizational advocacy for improved social determinants of health.
  • Advocate within the health system for conditions to promote SDH-oriented care, including remuneration arrangements and funding, and increased focus and exposure to SDH in undergraduate and postgraduate medical education.

8. Community engagement – Consider establishing a Community Advisory Committee to engage community organizations in influencing patient care decisions.

How is the Team Doing?
Measures of Success

Goal: Physicians and staff know the neighbourhoods in their catchment areas, and recognize at-risk populations and likely disease states.  The practice has strong connections with and takes full advantage of services in the community to best meet patients’ needs.

  • The team ensures continuity of the care being provided for patients in different settings and throughout the health care system, including community-based organizations.
  • The team is producing and analysing regular reports of EMR data on SDH indicators.