A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest

Abstract

Purpose Rural communities have unique economic and social structures, different disease burdens, and a more patchworked healthcare delivery system compared to urban counterparts. Yet research into addressing social determinants of health has focused on larger, urban, integrated health systems. Our study sought to understand capacities, facilitators, and barriers related to addressing social health needs across a collaborative of independent provider organizations in rural Northeastern Minnesota and Northwestern Wisconsin. Methods We conducted qualitative, semi-structured interviews with a purposive sample of 37 key informants from collaborative members including 4 stand-alone critical access hospitals, 3 critical access hospitals affiliated with primary care, 1 multi-clinic system, and 1 integrated regional health system. Findings Barriers were abundant and occurred at the organizational, community and policy levels. Rural providers described a lack of financial, labor, Internet, and community-based social services resources, a limited capacity to partner with other organizations, and workflows that were less than optimal for addressing SDOH. State Medicaid and other payer policies posed challenges that made it more difficult to use available resources, as did misaligned incentives between partners. While specific payer programs and organizational innovations helped facilitate their work, nothing was systemic. Relationships within the collaborative that allowed sharing of innovations and information were helpful, as was the role leadership played in promoting value-based care. Conclusions Policy change is needed to support rural providers in this work. Collaboration among rural health systems should be fostered to develop common protocols, promote value-based care, and offer economies of scale to leverage value-based payment. States can help align incentives and performance metrics across rural health care entities, engage payers in promoting value-based care, and bolster social service capacity.

Extent of Integration of Social Determinants of Health in Clinical Practice in Hospitals in Uganda

“…Data from the current study revealed a negative gradient from the patient level to the community level in terms of integration of social determinants into clinical practice, thus highlighting deficiencies in macro-level actions for integration of social determinants into clinical practice. The gradient was like what was observed among members of a health collaborative in rural Northeastern Minnesota and Northwestern Wisconsin [27].…”

Barriers and Facilitators to Integration of Social Determinants into Clinical Practice in Hospitals in Uganda

“…The others were not knowing the actions to undertake after identifying social factors [15], deficiencies in community social services and limitation in community-based resources. Some of the barriers highlighted in literature such as lack of a systematic screening process, lack of organized internal and external advocacy regarding the value of integration of social determinants into clinical practice, inappropriate payer policies, and misaligned incentives [22] and bias towards the medical model and treatment imperative, prior experiences of stereotypes and discrimination, physical fatigue [15] were not observed in this study. This difference is attributed to the difference in study setting and tools used.…”

A Systematic Review: Rural Health Disparities During the COVID-19 Pandemic in the United States

“…A qualitative study conducted by Dauner et al found that community health workers reported areas where resource shortages existed included the need for mental health clinicians; transportation; Internet; long-term care including memory care, respite, personal care services and hospice; specialty care; emergency medical services; public health department staffing; general workforce; and housing, specifically Section 8 housing [58]. Due to these shortages, their ability to address social determinants of health was very limited [58]. Resources such as transportation assistance was limited due to a complete lack of staff to assist or the inability for the healthcare worker themselves to participate due to legal hurdles.…”

“…Partner capacity appeared to be another challenge when addressing the needs of rural communities. Because social service partners did not have the capacity to take on more work, lower socioeconomic and less densely populated communities were adversely affected [58]. It was noted that in the wake of COVID-19, while some community partners noticed more engagement between each other, others stated that the pandemic exacerbated their internal issues and they struggled to stay aware of all the resources available between agencies [58].…”