Poor Social Determinants Linked to Worse Care and Outcomes for Patients With Lupus

A nurse-led analysis of an integrated care management program (iCMP) uncovered common social determinants of health (SDoH) in patients with systemic lupus erythematosus (SLE). Nurses were able to address any unmet needs prior to enrollment in the iCMP, which led investigators to believe that expanding similar programs would help to identify, document, and resolve common barriers that can create differences in care and outcomes, according to a study published in ACR Open.¹ SDoH concerns included food insecurity, housing instability, and financial concerns.

“Identification of SDoH‐related barriers and incorporation into existing algorithms used to identify high‐risk patients seems necessary to improve patient outcomes for those with SLE,” stated investigators. “Traditional models used to identify high‐risk patients often do not include SDoH variables, and they therefore identify high‐risk patients in a more downstream manner, once they are already suffering from potentially avoidable adverse outcomes.”

SLE disproportionately affects both racial and ethnic minorities, as well as those with a lower socioeconomic status, including those with public insurance, which contributes to an unequal proportion of adverse outcomes. To further the divide, the cost of SLE treatment increases over time. Programs like the iCMP can reduce health care costs and morbidity by using resources to provide quality preventative and ambulatory care, thus reducing avoidable acute care. This underlines the importance of an integrated care management strategy in alleviating SDoH issues.

Participants in the multi-hospital, primary care-based iCMP program were in the top 2% of patients diagnosed with SLE with medically and psychosocially complex cases. Electronic medical records were used to identify potential SDoH issues, physician and social worker notes prior to 1 year of enrollment were documented, and nurses assessed needs and coordinated care. Throughout iCMP enrollment, nurses and team members were responsible for the continuation of notes.

In a previous sample population of 110 patients, 86% reported at least 1 barrier related to rheumatology care or consistent medication use, and many exhibited symptoms of depression. Moreover, physicians interviewed explained that they frequently lack the incentive, time, and resources in order to screen for patients with SLE for SDoH. This is further proven by the ease of which the nurses in the iCMP program were able to uncover and address these concerns. Patients were identified as high risk via a machine learning algorithm, which utilizes factors such as age, sex, high-risk complex chronic conditions, and health care use to make that determination. SDoH were not included, although most participants concurrently reported these issues.

During the study, 69 patients with SLE were enrolled in the iCMP program based on insurance claims dated back to 12 months prior to and during the study. Patients were 93% female and had a mean (SD) age of 60.1 years. Ethnicities were reported as 56.5% White, 24.6% Black, 2.9% Asian or Pacific Islander, and 20.6% Hispanic.

SDoH needs, recorded both 12 months prior to enrollment and throughout, included access to food, medical care, medications, mental health services, childcare, education, transportation, and housing instability, with a specific focus on affording, accessing, or preparing food and difficulty obtaining medical care. Personal and neighborhood safety as well as emotional distress were also documented. SDoH were recorded in a REDCap form.

In the SLE group, 57% presented 1 or more SDoH issues prior to enrollment, compared with 94% during the program. iCMP nurses were able to address at least 1 of these concerns for 81% of patients, such as medication and mental health care access, financial insecurity, and transportation issues, and 75% of patients were connected with additional resources and support to aid in more long-term solutions. Resources included social work and mental health, elder care, pharmacists, home health, and substance abuse programs. Problems with medication access accounted for 66% of patients, transportation barriers accounted for 61%, and insurance affected 50% of this population. Additionally, 48% had difficulty accessing mental health resources, including scheduling appointments with therapy or social work resources, financial and housing concerns, and food insecurity. iCMP nurses were able to help patients find new insurance plans, door-to-door transportation, financial support, housing specialists, and help participants apply for food stamps.

Strengths of the study included the assessment of the integrated care management model to both document and address SDoH needs of this patient population, as well as the standardization of SDoH documentation inputted by iCMP nurses upon patients’ enrollment. Additionally, the potential effectiveness of the program was determined by access to available records due to the study’s retrospective nature. However, it was limited by differences in the length between pre-iCMP data collection and data collected during the study, which may have caused unintentional errors. More issues were discovered during enrollment, but more data were collected during this time. Lastly, while the limited sample size may impact generalizability, diversity of the patient population lead investigators to believe the results are reliable enough to compare to other urban academic hospitals with high-risk patient populations.

While further studies are needed, the results indicate that resolving the SDoH issues, via programs like the iCMP, may decrease healthcare costs while equalizing care and outcomes for both patients with SLE and those with complex chronic conditions in general.

“Because SDoH needs directly impact the care that patients access and because of the heightened burden of adverse outcomes among vulnerable populations, the health care system must develop and expand sustainable strategies like this iCMP to identify, document, and address these issues,” concluded investigators. “Deeper investigation is needed to determine the impact of addressing SDoH on improving preventive care as well as on reducing acute care use and disparities in longer‐term adverse outcomes among vulnerable populations.”

Reference:

Taber KA, Williams JN, Huang W, et al. Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus [published online ahead of print, 2021 Mar 29]. ACR Open Rheumatol. 2021;10.1002/acr2.11236. doi:10.1002/acr2.11236