How addressing Social Determinants of Health in Primary Care Improves Health Outcomes

About the Program

Category: Health (Best in Category)

Year: 2018

The neighborhoods we live in influence our behaviors and affect our health in profound ways. Social and economic factors in our communities are linked to physical and mental health disorders, illiteracy, homelessness, substance abuse, and higher mortality rates. Substance use including tobacco, alcohol, and drugs as well as poor or unsafe living conditions also result in poorer health outcomes with regard to chronic conditions. The Los Angeles County + USC Primary Care Adult Clinics seek to provide accessible, coordinated and comprehensive health care that addresses the behavioral health, mental health, and social needs of our patients in the primary care clinic setting. In our integrated behavioral health program, we universally screen patients for social and behavioral conditions, have improved patients’ access to behavioral health, mental health and social services, expanded the medical home team, and now deliver evidence-based interventions to manage social and behavioral conditions. In our model, the traditional medical team, including nursing staff, medical assistants, clerks and primary care providers, have been extensively trained in their respective roles in screening, diagnosis, management, and referral and tracking outcomes for social and behavioral conditions. In our new model, we have seen a tremendous increase in access to behavioral health and social services. Psychiatry and social workers functioning in our integrated model have increased their capacity to see patients, with psychiatrists seeing twice the volume of patients per session in our clinics compared to how many they see in their psychiatry clinics. Additionally, patients that received behavioral health services in our model had statistically significant improvements in their diabetes control, blood pressure control, and depression severity.