PATIENTS

SOCIAL DETERMINANTS OF HEALTH
IN YOUR CLINIC

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

 1. Collect SDH information – Prepare to collect and record in the EMR the following information as part of a patient record that can by analysed for the practice.

2. Create a welcoming environment for patients by following the 10 step laid out by EQUIP (Research to Equip Primary Healthcare for Equity)

At a minimum: Poverty – Ask all patients, “Do you ever have difficulty making ends meet at the end of the month?” (As per ​Poverty: A Clinical Tool for Primary Care Providers

Additional options:

Demographics: Ask about language, ethnicity, chronic illnesses, gender, sexual orientation and income, information vital to SDH-oriented care. This Measuring Health Equity form provides a verified format to use.

Support tool: Measuring Health Equity is a one-hour e-learning training course on collecting demographic information in health-care settings.

Adverse Child Experiences(link to workbook including ACEs questionnaires)– The ACE questionnaire measures sources of stress that children may suffer early in life, including abuse, neglect, violence and serious household dysfunction. Considerable and prolonged stress in childhood has life-long consequences on physical and mental health and well-being, including possible disruption of early brain development, compromised nervous and immune systems, behavioural problems and chronic illness.

Attachment, medical and psychiatric issues– BC’s Health Connections clinic has developed the AMPs questionnaire to delve into SDH issues. Please note that, while the AMPS tool has not yet been validated, it has been used since 2014 within Vancouver Coastal Health’s owned and operated CHCs, to support over 450 clients.

3. Develop individualized plans for patients, including:

Income support:  Poverty: A Clinical Tool for Primary Care Providers outlines income support options for your patients, provided they have completed their tax forms. Ask all patients, “Have you filled out and sent in your tax forms?” If not, connect them with Free Community Tax Clinics.

Social and other support: Access community resources available to assist with housing, food and basic needs, education/training, employment, transportation and legal/advocacy support. Research local connections with the team to link patients to needed services, or access bc211 for a list of services available. Call the trained Information and Referral Specialists at ‘211’ for guidance on individual patients.

4. Support women experiencing violence by following EQUIP’s “Top 10 Things Any Provider Can Do”.

5. Introduce a Feedback Box in the waiting room, and ask specific questions related to SDH on feedback cards.

​6. Advocacy – Political change is necessary for full system-wide implementation of SDH. If you are keen, consider acting as a Health Advocate for your patient. Learn about advocacy from the CMA training program. Help is also available from social workers, health navigators and programs such as Basics for Health

7. Health Literacy – Become familiar with health literacy tools, to assess patients’ capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.

​8. Patient engagement – Consider establishing a Patient Advisory Committee or other mechanisms to give patients an active voice in their car
​

How is the Team Doing?
Measures of Success

Goal: Patients needs are understood and they are provided with comprehensive, continuous care. Criteria include:

  • Care and caregivers are person-focused and provide services (including those in the community) that are responsive to patients’ feelings, preferences and expectations.
  • Patients, their families and their personal caregivers are listened to and respected as active participants in their ongoing care.
  • Electronic Medical Records exist, noting:
    • The number of patients committed to physicians in the practice;
    • Patients’ demographic information, employment status, living situations, social supports and any benefits they receive;
    • Patients’ response to the Poverty Intervention screen;
    • Patients’ ACE scores, if administered.

PRAPARE provides extensive context on how to Develop a Data Strategy and Understand and Evaluate the Data as the team moves forward.