Social Determinants of Health May Improve With Home Care | myNEXUS®

12 . 11 . 2020

SDOHWe hear a lot about how social determinants of health (SDOH) can influence and even predict health situations in both acute settings and in patients living with chronic disease. SDOH include such environmental factors as socioeconomic status, education, neighborhood, and physical environment, employment, social support networks, as well as access to health care.While the evidence linking SDOH to health outcomes is still evolving, we already know that, among other impacts, social barriers to care can lead to early hospital readmission post discharge2, increased mortality2, and poor glycemic control in patients living with diabetes. Yet as important as SDOH are to health outcomes, we know that only 24% of hospitals and 16% of physician practices report screening for these crucial environmental factors.4

Managing Social Barriers to Care

Given that the healthcare system has not yet found a solution to ensuring that all patients are screened for SDOH, let alone solving for such barriers, the question arises “can skilled home care clinicians help identify and mitigate social barriers to care?”  myNEXUS believes that the answer to this question is a resounding “yes!”  To begin with, the risk profile of homebound patients is higher than the average Medicare beneficiary. “Completely homebound individuals were more likely to be older, female, non-White and have less education and income than the non-homebound population, to have more chronic conditions, and to have been hospitalized in the last 12 months. Only 11.9 % of completely homebound individuals reported receiving primary care services at home.”5  Furthermore, home care providers are uniquely positioned to identify environmental factors that could negatively impact a patient’s health. As home care involves a face to face interaction between the patient and the nurse, physical therapist, occupational therapist, and/or social worker, there is an opportunity to assess whether or not the patient has a sociodemographic barrier to care.

Presence is Key

The presence of a clinician in the home provides an opportunity to identify, document, and potentially implement solutions to mitigate these barriers. For example, a home care nurse can gather the patient’s medications and determine which ones are currently being taken as prescribed. A social worker can assess the surroundings for evidence of financial hardship and/or risks to personal safety. A therapist can assess the home for fall risks or barriers to activities of daily living. While case managers routinely ask about these factors, they typically do so from a remote location via telephone. Nothing beats “boots on the ground.”  Additionally, once a barrier is identified, the clinician and her/his parent agency are uniquely positioned to develop the solution. This is because the clinician and agency are often local and more often than not the home care clinician has gained the trust of the patient.

Therefore, as we think about the value that home care providers can bring to patients, we should be thinking not only about traditional skilled nursing care and therapies but also about the ways in which we can capitalize on the presence of a skilled clinical workforce in the home.


  1. Artiga S, Hinton E. Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. KFF Issue Brief. May 2018
  2. Calvillo-King L, Arnold D, Eubank KJ, et al. Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review. J Gen Intern Med. 2013 Feb;28(2):269-82.
  3. Walker RJ, Gebregziabher M, Martin-Harris B, et al. Quantifying Direct Effects of Social Determinants of Health on Glycemic Control in Adults with Type 2 Diabetes. Diabetes Technol Ther. 2015 Feb 1; 17(2): 80–87
  4. Fraze TK, Brewster AL, Lewis VA, et al. Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals. JAMA Netw Open. 2019 Sep; 2(9): e1911514.
  5. Ornstein KA, Leff B, Covinsky K, et al. The epidemiology of the homebound in the United States. JAMA Intern Med. 2015 Jul: 175(7) 1180-1186.