Advanced care planning (ACP) is a process that supports patients in understanding and defining their values, goals, and preferences regarding future medical care when facing a serious illness. The goal of ACP is to help ensure that people receive medical care that is consistent with these preferences. This can be a very delicate and difficult conversation to have with care teams or loved ones and certain social factors can become additional barriers in having these advance care discussions. Some of these factors fall under the umbrella of social determinants of health (SDoH) and should be adequately understood and addressed in order to facilitate having conversations surrounding future goals of care. 

What are Social Determinants of Health? 

Social determinants are the economic and social conditions that influence individual and group differences in health status. The World Health Organization (WHO) defines social determinants of health as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. Social determinants can have an enormous impact on an individual’s ability to engage with the healthcare system and maintain their wellbeing. They account for 60% of health outcomes while healthcare accounts for just 20% and genetics for 20%. Therefore, it is very important to include SDoH factors in population health management as an opportunity to improve patient outcomes. 

The CDC groups SDoH into five domains: 

  • Economic stability –such as poverty, employment, food security, and housing stability
  • Education access and quality – such as graduating from high school, enrollment in higher education, educational attainment in general, language and literacy, and early childhood education and development
  • Healthcare access and quality – such as access to healthcare, access to primary care, health insurance coverage, and health literacy
  • Social and community context – cohesion within a community, civic participation, discrimination, conditions in the workplace, and incarceration
  • Neighborhood and built environment – quality of housing, access to transportation, availability of healthy foods, air and water quality, and neighborhood crime and violence

Often, the populations that fall under these domains are at-risk. These patients are less able to access care and more likely to experience poor health outcomes over time. Many patients face challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. 

Studies have shown that these high-risk, high-cost populations are less likely to discuss care goals, which may result in receiving care that is unwanted or not aligned with their wishes and values. Recognizing the social factors that influence their health decisions can lead to the development of more effective treatment plans and address social needs through appropriate referrals to ensure access to adequate support such as palliative care and advance care planning.

How Palliative Care Can Address SDoH

Palliative care refers to care provided for those with a progressive, advanced disease. Palliative care identifies and treats symptoms which may be physical, emotional, spiritual, or social and because it is based on individual needs, the services offered can be diverse.  The goal of palliative care is to provide coordinated care services that improve the patient’s life and to provide the right care at the right time for each patient given their condition and situation. However, barriers to referring palliative care specialists often are related to the lack of understanding or conflicting values between patients and providers. Opportunities to improve referral include telemedicine and outpatient palliative care services such as home care.

Engaging palliative care teams for high-risk populations can put services in place to meet the needs of patients and their families, especially those that address specific SDoH, including the ability to assess the home environment, safety, nutrition, health literacy and access to care. Palliative care delivered in the home can help patients address these needs and avoid costly and unnecessary healthcare utilization.  Home-based palliative care could reduce societal health care costs by $103 billion within the next 20 years, according to a 2019 Florida TaxWatch report.  

Advance Care Planning and SDoH

When advance care planning is included in the continuum of care, patients receive the care that meets their goals and values. Effective population health strategies focus on coordinating care across the continuum. ACP fills a critical gap for high-risk, high-cost patients, who are the most vulnerable to falling through the cracks. Successful ACP initiatives ensure that these vital conversations are documented and readily available for patients as they move across healthcare settings, improving communication and ensuring better transitions of care throughout the course of illness.  

 Advance care planning is best done with consideration of the patient’s relationships, culture and understanding of the patient’s background and socioeconomic conditions. This means taking the time to speak with the patient, asking the right questions, and having conversations surrounding social barriers that could affect their goals and desire for future care.  However, social determinants such as distrust of the health care system, cultural beliefs about death and language barriers can dissuade some patients from engaging in conversations surrounding future goals of care. 

Recent research from the Coalition to Transform Care (C-TAC) also indicates that there are broad disparities that exist in access to advance care planning among some demographic groups, often along racial or socioeconomic lines. The underlying causes of lower prevalence of advance care planning are multifactorial. Some groups lack access to advance care planning and are faced with high costs of care or a lack of health insurance to pay for those services. A lack of diversity among the workforce to conduct these conversations with patients also contributes to limited utilization among underserved populations.

Increased access to advance care planning can have a considerable impact on the quality of life for patients and their loved ones. Understanding the patient’s wishes may reduce unnecessary pain from unhelpful or unwanted medical procedures, avoid unwanted hospitalizations, minimize stress and potential conflicts between patients and families. ACP can facilitate in providing patients with the right care, at the right time, in the appropriate setting. Numerous studies have demonstrated that goal-concordant care is associated with better quality and patient satisfaction, improved health of the population, and controlled health care costs.

How Iris ACP Can Help 

Iris specializes in creating high-quality, industry-leading advance care plans by providing patients with a tailored, person-centered care planning experience. By recognizing and addressing social factors that can influence health and care goals, our health care planning experts are able to provide compassionate and personalized support to patients facing any number of socioeconomic challenges and obstacles in their daily lives while helping them make educated, scenario-based decisions about their future care goals. 

How Iris ACP facilitations can aid in successful member engagement that addresses SDoH:

  • Our ACP conversations can be facilitated via phone or video conferencing, alleviating any transportation barriers the patient may face. 
  • Our multi-lingual health care planning experts and documentation is available in various languages to help overcome language barriers that may hinder members from completing advance directives. 
  • Our expert health care planning experts can provide disease specific education and in-depth information to clear up any confusion surrounding treatment options so that patients can make informed care decisions.
  • Our documentation includes advance directives along with a clear care summary that is shared with family members and medical care teams to ensure that treatment decisions are in concordance with their goals, preferences and values.
  • Our extensive palliative care network can ensure that both patients and their caregivers have the emotional and social support required to improve their quality of life. 

Organizations that make ACP a part of their population health strategies will improve quality of care delivered to patients and enhance the patient experience while better managing and allocating healthcare resources.   If you’d like to see how Iris can help your health plan achieve high-quality care plans, get in touch with us today.