Nurses have always known that holistic approaches improve patients’ quality of life. Historically, this meant asking questions about a patient’s behavioral, medical, and social care. Today, those questions have expanded to include a patient’s social determinants of health (SDOH).
UNDERSTANDING SOCIAL DETERMINANTS OF HEALTH
Social determinants of health are conditions in the places where people are born, live, learn, work, play, and age that affect their health and quality of life. These conditions fall into five categories: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. While medical care plays a
role, other factors such as social determinants and health behaviors significantly influence overall health and well-being.
Identifying the conditions facing a patient is just the beginning. To improve quality of life, care providers must also find ways
to reduce the negative impacts of these determinants. However, with a US health care system largely focused on treating disease rather than early intervention, significant gaps remain for integrating SDOH assessment into practice.
As patient advocates, nurses are uniquely positioned to identify these gaps and propose solutions. At the University of Utah College of Nursing (CON), two initiatives demonstrate how practitioners and graduates improve nursing practice by addressing SDOH in innovative ways.
USING COMMUNITY HEALTH WORKERS TO BRIDGE GAPS FOR OLDER ADULTS
Older adults often face unique challenges related to SDOH, including food insecurity, housing instability, financial stress, and social isolation. As populations age, these issues grow more pressing.
Amanda Keddington, DNP, a clinical instructor and CON graduate, encountered these challenges firsthand during her doctoral training. Working with a large health care center, she explored how community health workers (CHWs) could address unmet social needs for older adults.
CHWs are trusted members of their communities who are trained to provide education and support. Their deep understanding of local challenges allows them to help patients navigate roadblocks to care. Keddington recalls spending time in the emergency room and seeing older patients return repeatedly due to unresolved social needs.
“They’d come to the emergency department because they couldn’t regularly see a health care provider or weren’t able to care for themselves because of social needs,” she explains. “So, when I found out more about what CHWs can do, it was a light bulb moment for me.”
Keddington analyzed more than 5,000 social needs surveys completed by older adults at three geriatric clinics. Every patient reported at least one social need impacting their health. She discovered that clinic staff were referring patients to the 2-1-1 helpline, which connects individuals to local resources.
While 2-1-1 is a valuable tool, Keddington proposed embedding a CHW into clinic care teams to provide personalized, ongoing support.
“A CHW is a more specialized role and would really know the population and what they need and how to overcome issues,” she says. “Having a CHW who can update care teams on patient progress and navigate changing needs could significantly improve outcomes.” Training and certification programs are available for people interested in learning more about CHWs or becoming one in Utah. Research by CON faculty Andrea Wallace, PhD, and Brenda Luther, PhD, demonstrates how these professionals can improve patient care, enhance access to services, and address social and environmental factors that influence well-being through tools like SDOH screening for emergency department clinicians.
INCREASING AWARENESS OF RURAL ONCOLOGY PROGRAMS
In rural communities, barriers like transportation, limited local care, and a lack of specialists exacerbate preventable hospitalizations. For patients with chronic or progressive illnesses, this often means a cycle of emergency care instead of proactive treatment.
Angela Fausett, DNP, a CON graduate and Huntsman Cancer Institute Huntsman at HomeTM care manager, saw this pattern often. Although Rural Hunstman at Home offered a proven model of hospital-level cancer care delivered in patients’ homes, referrals to the program were low.
“Rural patients with progressive, chronic illnesses are in this cycle of emergency help, putting out fires instead of treating things because of the distance they have to travel,” Fausett explains. “This program already exists and has shown great outcomes. I wanted to figure out what was the missing piece and see how we could connect people to this program.”
Fausett began by gathering feedback from oncology providers about their knowledge of the Rural Hunstman at Home program. She found that 45% of providers were unaware of the program, and 64% had never referred a patient. Top concerns included access to care, symptom management, and patient follow-up.
Using this data, Fausett created an information toolkit, complete with promotional materials
for providers and patients. She conducted educational workshops for oncology providers and placed postcards with program details in clinics. She also reviewed patient records to identify eligible individuals and reached out to their providers for referrals.
After 100 days, referrals to the program from outpatient clinics increased by 20%.
“By improving awareness of [Rural Huntsman at Home], we will increase access to care and, hopefully, decrease ER visits and missed appointments,” Fausett says. “But these patients will also feel some peace by having the safety net of having someone in their corner.”
Patients and providers in Utah’s Carbon, Emery, and Grand counties can now access details about the program by visiting the website or by scanning QR codes found in clinics. These efforts highlight the importance of increasing awareness and education around existing programs to enhance care in underserved communities.
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