Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice

DeVoe, Jennifer E.; Bazemore, Andrew; Cottrell, Erika; Likumahuwa-Ackman, Sonja; Grandmont, Jené; Spach, Natalie; Gold, Rachel

doi:10.1370/afm.1903

Cited by 157 publications

(155 citation statements)

References 34 publications

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“…Tobacco counseling competes with treatment of acute symptoms, management of multiple chronic diseases, and other preventive services, as well as suggestions to integrate clinical practice with community health organizations and to coordinate with community health workers to address patients' social determinants of health. [11][12][13][14][15][16][17][18][19][20] Yarnall and colleagues estimated that a physician with a panel of 2,500 patients would need 7.4 hours per day to deliver evidence-based preventive services 21 and as many as 10.6 hours to provide disease management for chronic conditions. 22 Though Altschuler et al estimated that a physician could care for a panel of 2,000 patients with the maximum feasible delegation of preventive services and chronic disease care to other primary care team members, 23 that level of delegation may be a long time coming.…”

Section: Introductionmentioning

confidence: 99%

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

et al. 2017

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PURPOSE To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation. METHODSWe conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews.RESULTS Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates. CONCLUSIONSBrief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.

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Section: Introductionmentioning

confidence: 99%

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

et al. 2017

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“…10,11,12 Primary care practices should identify pragmatic steps to link patients to community resources. Health care payers implementing population-based payment models should support family physicians adopting these interventions.…”

Section: Attend To the Social Determinants Of Healthmentioning

confidence: 99%

Perspectives in Primary Care: Family Medicine in a Divided Nation

Romano

Grumbach

2017

Ann Fam Med

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“…[2][3][4][5][6][7][8][9][10] The article by DeVoe and colleagues in this issue of Annals recommends a very reasonable approach of collecting community and patient data before taking individual patient and panel actions and then adding automated supports. 11 Before we ask practices to take on these tasks, however, we need much more evidence that it is both feasible and effective. We also need to know that taking on this added responsibility won't divert care systems from the important task of transforming the way we accomplish existing responsibilities and won't cause clinic personnel even greater stress.…”

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confidence: 99%

Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No.

Solberg

2016

Ann Fam Med

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102R ecently, the recognition that medical care may contribute less to overall health than other aspects of people's lives do has led policy makers, academics, and even some physicians to argue that clinicians should make screening and action on the social determinants of health their responsibility. Although such an expectation is understandable, the additional requirements (that will fall largely on primary care) are likely to have serious unintended consequences and be unlikely to produce the hopedfor benefits.First, anyone proposing any new responsibilities for primary care clinicians must be unaware of the degree to which most of them already feel overworked, stressed, and discouraged. There is little joy in Mudville. Shanafelt et al's national survey of 7,300 physicians in 2012 reported that 46% of them had at least 1 symptom of burnout, 38% screened positive for depression, and 37% felt that their work schedule didn't leave enough time for personal or family life.1 Those in family or general internal medicine were at the wrong end of each of these spectrums among all medical specialties. Our recent unpublished survey from the 2013 COMPASS project of 700 primary care physicians in 18 widely diverse medical groups in 8 states found 30% reported feeling burned out; 12 months later this number had risen to 37%. Will an additional large responsibility help this unsustainable situation?Much of this workload and stress comes from all of the expectations that have especially been added for primary care physicians since I began doing patient care 43 years ago. Over the years, society seems to have decided that diagnosing and treating the problems that patients brought to our door was not adequate. Clinicians and care systems must now also screen and act upon assorted preventive services, fully control chronic conditions (not just relieve symptoms), provide the mental health care that an insufficient number of mental health professionals cannot, help patients modify a wide range of health behaviors, coordinate with a variety of community agencies, provide much more complete documentation, complete a bewildering number of forms, and proactively reach out to all of the people who had ever been seen in the practice in order to practice population medicine. In order to facilitate these tasks, clinicians have also been required to use electronic medical records and lead multidisciplinary teams that, while offering some clear advantages, also take a great deal of time. Many clinicians feel these added responsibilities are inefficient and not why they went into medicine. Finally, many of those social determinants (broken and dysfunctional families, substance abuse, homelessness, etc) have become much more frequent and problematic, often requiring greater time and adding stress to providing even traditional medical services.Simultaneously, we are in the midst of a great national effort to transform primary care in order to achieve much-needed improvements in quality, costs, and patient experience. Making all the changes in...

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Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice

Cited by 157 publications

References 34 publications

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

Perspectives in Primary Care: Family Medicine in a Divided Nation

Theory vs Practice: Should Primary Care Practice Take on Social Determinants of Health Now? No.

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