Breaking Down Barriers
By addressing social determinants of health — those nonmedical factors that influence patient outcomes —DAP Health is creating equity.
As seen in Issue 4 of DAP Health magazine
Words by Ellen Bluestein
In its efforts to deliver care based on the needs of the individual, DAP Health’s innovative, whole-person approach continues to extend beyond the medical to address the systemic and societal forces that often prevent patients from receiving that care.
Known as social determinants of health (SDOH), these factors are the outside influences that impact a patient’s ability to seek or maintain health care. “They’re the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” says DAP Health Chief of Community Health C.J. Tobe. “Typically, there are five different categories that social determinants of health are broken into: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and then social and community context.” Each can have a profound effect on health outcomes.
Now that DAP Health oversees a total of 25 clinics in Riverside and San Diego counties, this broadened area of service brings increased challenges to care. “We recognize that addressing social determinants of health is important to improve patient outcomes,” says Enhanced Care Management Operations Supervisor Claudia Barron. “First and most importantly, we conduct patient assessments, and we go beyond medical conditions. Our case management teams are trained to address social determinants of health, like housing insecurity, transportation barriers, financial challenges. And we also understand that every patient is unique and has their unique challenges. So, we focus on creating personal care plans. We also get trained by our health plans so that we can connect patients with resources.”
“We early on learned that having a great doctor and fabulous medicine is not enough,” says Senior Director of Social Services Zayda Welden, who oversees the nonmedical programs and services for HIV clients. “All these other factors are so important, or as important, as having the best infection specialist.”
Welden continues: “Clients have the best intentions, but if they cannot get here because they are living in the back dumpster of some building that offers shade — and if they leave, someone else will come in and take the place — they’re not going to leave,” she says. “If someone is not able to walk to the bus stop two miles to get on the bus and come in for the appointment, they’re not going to come in. If they don’t have money to buy gas, they’re not going to come in. So, we can have the best clinic and the best treatment available. If they are not coming in, then our work is not done.”
To address this barrier, DAP Health has instituted transportation programs. “We have the ability to give clients bus passes and gas cards,” says Welden. “Now, not everybody has a car, so
we have bus passes available for them. We have two kinds: one that is for seniors and disabled individuals, and one that is a regular monthly bus pass.”
It should be noted that, at this time, the medical transportation benefit is funded through grant programs limiting access to HIV-positive clients living in specific geographic areas who qualify.
Welden also cites food insecurity as a negative social determinant of health. “Every patient who comes into the clinic gets asked a few questions in regard to food insecurity,” she says. “If they say, ‘Yes, I need a bag of food for the next two or three days,’ then we will provide that bag of food, no questions asked.” DAP Health’s nutritionist carefully chooses the nonperishable items that go into the bags, ensuring that they are both shelf stable and nutritionally substantive.
“A lot of people downplay the importance of access to good, nutritious food,” says Tobe. “That’s going to be a social determinant of health — making sure people are able to eat several balanced meals per day. There’s fresh water. We found out that in our Oasis clinic, there’s not fresh water. That’s another social determinant of health.”
At said Oasis clinic (also known as Centro Medico Oasis, located in the town of Thermal), most clients work in agriculture, an often-grueling business with long hours and low pay that can profoundly affect health and well-being. “What we’ve gathered from talking to patients is that not all of them have or work for a company full-time where they get vacation, benefits, and all that,” says Oasis Clinic Manager Israel Ochoa. “The majority of them get three sick days, so once they’re gone, they don’t get paid. A lot of them would rather work unless it’s really, really necessary, or they’re really sick. They don’t have the luxury of benefits.”
Some clients also don’t have the luxury of literacy. “Centro Medico Oasis is 95% Spanish-speaking,” says Ochoa. However, for roughly 60% of the community, the first language is Purépecha, a Spanish dialect from Central Mexico. While these clients speak Spanish, there are some differences that prevent them from fully understanding it. When it comes to reading and writing, it’s Purépecha, not Spanish, that’s used. Most of the staff at the clinic speak English and Spanish, but there are times — during mental health appointments, for example — when clients and providers need interpretation assistance. For that, an online translation service is employed.
From environment to education, work to worship, many factors influence health outcomes. “Negative social determinants of health…don’t discriminate. Anybody can face them,” concludes Tobe. Identifying and implementing programs to address them is the key to combatting them. “It’s really all about creating different access points or ways for people to obtain different services,” he continues. “It’s coming up with innovative ways to be able to eliminate that red tape, reduce those barriers, and meet people where they are that’s going to help support people living their healthiest and best life.
“With this marriage between DAP Health and Borrego Health, I think we’ll be able to take a lot of the foundational work that we’ve done…[and] then build on that infrastructure and replicate different programs — or even create new programs to address different social determinants of health for our complex patient population.”