Defining the Social Determinants of Mental Health (SDoMH) is an unparalleled opportunity for integrated and wholistic health care models moving forward. But my enthusiasm has me jumping ahead. Why should the SDoMH receive unique attention by the the industry, not to mention behavioral health professionals (BHPs) and Doctors in Behavioral Health (DBHs). One might think the industry’s fixation on the Social Determinants of Health (SDoH), is sufficient; NOT! Let me provide a brief overview, with validation and action items to engage your perspective and entice your energies.
Level Setting the SDoH Foundation
The health and behavioral health industry is fixated on the Social Determinants of Health (SDoH); the non-clinical psychosocial and socioeconomic circumstances that contribute to healthcare outcomes. The five domains affirmed by Healthy People 2030 (U.S. Department of Health and Human Services, 2020) and their respective elements top the priority list for every organization:
- Economic stability
- Education access and quality
- Health care access and quality
- Neighborhood and built environment
- Social and community context
There is substantial evidence-based validation of how the SDoH impact the financial bottom line for the industry, attributed to:
- National Health Expenditures of $3.6 trillion annually (CMS, 2019)
- Over 50% of hospital readmissions (Gooch, 2018)
- $200 billion in premature deaths (Ayanian, 2015)
- Inadequate chronic illness management, with
- 4.3 million preventable emergency department (ED) visits, and
- 30% of unnecessary visits, and
- 86% of chronic health spending overall (Premier, 2019)
The numbers and daily emerging reports are endless, and it would be easy to go on. The data is compelling and the prime focus of society. Even amid the current pandemic, health disparities are a constant theme. However, while the health and wellness of populations mandates critical attention, other concerning matters warrant notice and action, especially in the context of mental health disparities.
Expanding SDoH to SDoMH: Defining Action Items
Mental health is now the largest driver of unnecessary ED visits, with the associated costs for patients with behavioral health needs costing upwards of $2264 per visit (Institute for Healthcare Improvement and Wellbeing Trust, 2020). The numbers speak to longstanding needs across those populations most in need. Members of racial and ethnic minority groups have been identified as (NIMH, 2016):
- less likely to access to mental health,
- use community mental health less hoped,
- more likely to obtain care from EDs, hospitalizations,
- and have that care be emergent, band-aid fixes only.
These realities do nothing to enhance the quality of mental health care, putting the Triple/Quadruple Aim at gross risk. If you think the industry’s quality compass for population-based care is only applicable to physical health, think again! Integration of a quality health and behavioral health experience is the preferred model of care to achieve the best outcomes (Health Research and Educational Trust, 2016), and that concept is something BHCs and DBHs can relate to. Yet, despite the promise, this level of integration remains one of the most challenging issues facing health systems and the industry today. This issue exists even amid significant data that speaks to how adults with severe mental illness (SMI) are more prone to chronic illnesses, die on average of a 10-20 years earlier than populations without SMI, and live amid the inequities of the SDoH (Health Research and Educational Trust, 2016; SAMHSA, 2016); but lest I digress.
Mental health and its accompanying disparities, are as much a public health issue as racism itself, affirmed in over 20 states and 700 counties in the U.S, and rising across the globe. In fact, mental health and racism are intrinsically linked to, and responsible for existing inequities in diagnosis, treatment and management of mental health illness (Compton & Shim, 2015). While behavioral health practitioners experience these inequities daily, data to this end is not present in the literature; certain not to rate it appears for physical health disparities. Considerable research affirms correlations between physical health outcomes, the SDoH, and health inequities (e.g., race, ethnicity, education, socioeconomic status, access to care) (Compton and Shim, 2015; Fink-Samnick, 2019; Williams, et. al., 2019). Action item #1: We can and must do better in approaching the interplay of the SDoH with SDoMH, and leveraging the evidence.
BHPs, and other providers must explore the true etiology of chronic mental illness exacerbation, as in how unemployment derails access to mental health care in the form of persons being under and uninsured, institutional bias and stigma by providers in accepting public and third party insurers (e.g., Medicaid, Medicaid, dual eligibles), reduced reimbursement for psychiatric and mental health providers, along with provider deserts and shortages. The gaps in culturally-informed and inclusive treatment providers and interventions must also be mitigated. Let’s add on the necessary shift in treatment approaches themselves. Implicit bias, and “a blame the patient perspective” can be conveyed when practitioners use verbiage as “treatment non-compliant”. Instead, emphasis must transition to behaviors and interventions that foster patient engagement, motivation, and most importantly address treatment adherence (Williams, et. al., 2019). Action item #2: Shift the narrative to reduce patient blame, bias, and mental health stigma overall.
A focus on the SDoMH will promote a more informed approach to care by practitioners, but also policy makers who advocate for necessary funding. Judgements, generalizations and false narratives can easily emerge, such as poverty equals increased substance use or intergenerational teen pregnancy and family violence, rather than poverty as a driver of trauma, victimization and other factors that exacerbation mental health conditions (Compton & Shim, 2015). A dedicated SDoMH perspective will promote less punitive approaches to mental health and treatment mandated by more vulnerable, disenfranchised, and marginable populations. Mental health stigma is a fierce factor to impact racial, ethnic, and other cultural communities engaging in treatment processes. Experienced, internalized, and even anticipated stigmas easily obstruct meaningful behavioral health intervention by those persons most in need (Cardoso, et al., 2020). To combat these negative disruptors, BHPs, and programs must employ strength-based paradigms and tools that account for each individual in the scope of their reality, including beliefs of the value of mental health and treatment. Action item #3: View each person and population with respect of the human condition; where they are at, as opposed to where the well-intended provider would like that person to be.
Finally, there must be assessment and consideration of trauma (whether past or present) in the context of overall health and mental health prevention and wellness. Much can be learned from the recent generation of short-term tools incorporated to approach chronic illness, and their role in enhancing more successful outcomes for patients (Hudson, 2016). Integration of the Advanced Childhood Experiences (ACEs), and other trauma-formed mental health assessment target the unique person and population in the scope of their trauma, and its impact on neurocognitive, social, and behavioral development; factors that exacerbate the emergence of assorted diagnoses (e.g., ADHD, oppositional-defiant disorder, borderline and other personality disorders, major depressive disorder, bipolar (1 and 2), peri and post-partum depression). The DASS-21 hones in on stress, anxiety, depression; all known to exacerbate any and severe mental illnesses (AMI, SMI). Action item #4: Use the tools to assess and address health and mental health prevention and wellness, as a matched set.
Amplifying SDoMH Action
Dedicated SDoMH action formalizes an industry-wide prioritizing of a strategic approach to the SDoMH guided by:
A. Prevention
B. Promotion, and
C. Wellness
These imperatives are empowering thriving SDoH programming across the globe. DBH’s value grounding practice and reality with theory, so here’s a concept to get you thinking. Employing a theoretical framework based on Bronfenbrenner’s social ecological model will fuel needed organization of macro (system), meso (community), and micro (patient) perspectives. These dynamic domains can be siloed, and must be replaced by collaborative partnerships across sectors. In this way attention to whole person, or wholistic care can be realized through initiatives that encompass the pathophysiology, psychopathology, and psychosocial circumstances of patient populations. A lens focused on the collective expertise of upstream influencers (e.g., federal and state government, public policy, reimbursement, systematic racism) will minimize downstream disruptions to care access. This concerted approach will spur needed mental health promotion in terms of funding, sustainable program development and implementation, particularly in those areas most at need. One final Action item, #5: BHPs, DBHs and the industry as a whole must lead the charge to:
- build community collaboratives that break down silos in care,
- affirm attention to fully integrated, if not wholistic care models,
- use their unique expertise to inform policies that drive sustainable funding and reimbursement of providers, practitioners and programs, and
- commit to dedicated attention to the SDoMH.
This blog first appeared as an assignment for Cummings Graduate Institute of Behavioral Health Studies, DBH: 9016, Fall 2020. #DBH #DBHRocks #SDoMH
The patient infographic, the Social Determinants of Mental Health, is attached below
Bio: Ellen Fink-Samnick is an award-winning industry thought leader who empowers healthcare's interprofessional workforce. She is a sought out professional speaker, author, and educator for her innovative content and vibrant presence. Ellen is an international national expert on the Social Determinants of Health, Workplace Bullying, Professional Ethics, Professional Case Management Practice, and Wholistic Case Management™. Her recent books include, The Essential Guide to Interprofessional Ethics for Healthcare Case Management The Social Determinants of Health: Case Management's Next Frontier, and upcoming End of Life for Case Management, all through HCPro. Along with several academic teaching appointments, Ellen is Lead for RISE's SDoH Community and Doctor in Behavioral Health (DBH) candidate at Cummings Graduate Institute for Behavioral Health Studies. View more on her LinkedIn Profile.
References
Ayanian, J. (2015, October 1). The costs of racial disparities in healthcare. Harvard Business Review. Retrieved from https://hbr.org/2015/10/the-co...ities-in-health-care
Gooch, K. (2018, October 25). SDoH contributes to over ½ of readmissions, Beckers Hospital News, Retrieved from https://www.beckershospitalrev...ons-study-finds.html
Centers for Medicaid & Medicare Services (2019) Historical, National health expenditures data. Retrieved from https://www.cms.gov/Research-S...thAccountsHistorical
Compton, M.T., & Shim, R.S. (2015). The social determinants of mental health. American Psychiatric Association
Fink-Samnick, E. (2019). The social determinants of health: case management’s next frontier; HCPro
Fink-Samnick, E. (2020) The Social Determinants of Mental Health (SDoMH) Patient education infographic, DBH 9016 Fall 2020; Cummings Graduate Institute of Behavioral Health Studies
Health Research & Educational Trust. (2016, February). Triple Aim Strategies to Improve Behavioral Health Care: Health Research & Educational Trust. Accessed at www.hpoe.org
Hudson D. L. (2016). Quality over quantity: integrating mental health assessment tools into primary care practice. The Permanente journal, 20(3), 15–148. https://doi.org/10.7812/TPP/15-148
Institute of Healthcare Improvement & Well-Being Trust (2020). Improving behavioral healthcare in the emergency department, Retrieved http://www.ihi.org/resources/P...nt-and-Upstream.aspx
National Institutes of Mental Health (NIMH) (2016). Minority health and mental health disparities program, National Institutes of Mental Health, Retrieved from https://www.nimh.nih.gov/about/organization/gmh/minority-health-and-mental-health-disparities-program.shtml#3
Premier (2019)Ready, risk, reward: improving care for patients with chronic conditions. Retrieved from https://www.premierinc.com
Substance Abuse and Mental Health Services Administration (SAMHSA) (2016) Serious mental illness among adults below the poverty line. Retrieved from https://www.samhsa.gov/data/si.../Spotlight-2720.html
U.S. Department of Health and Human Services (2020). Social determinants of health, healthy people 2030; Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov/healthypeop...-determinants-health
Williams, M.T., Rosen, T., Kramer, J.W. (2019). Turner, E.A., Malone, C.M., & Douglas, C. Chapter 2, Barriers to mental health treatments for african americans: applying a model of treatment initiation to reduce disparities, in Eliminating race-based mental health disparities. Context Press
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