Three Core Obstacles to Improving Social Determinants of Health

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Healthcare is ideally positioned to catalyze the critical reorganization necessary to improve social determinants of health to help both healthcare and education succeed. It can take advantage of existing funding to help connect and grow community partnerships focused on sustainable improvement.

But improving problems generated by unwanted system behavior (failure to improve SDOH) requires systems and thinking that are focused on the whole more than the parts being changed, and there are three reasons healthcare is currently waging an uphill battle.

  1. Healthcare’s perspective is limited.

  2. A sustainable solution requires new ways of thinking.

  3. Core community services lack effective system integration.

Healthcare’s perspective is limited.

It is well known that socially complex patients have or develop greater need for healthcare. One study by Tracy L. Johnson, et al., looked at “super utilizing” patients and found that just 3% of patients are responsible for 30% of cost. More importantly, this percentage persisted even though at 7 months 50% of the original group were no longer high healthcare utilizers and only 28% remained 12 months after being identified. While the numbers are different, this is true in rural and urban areas. Medicine only interacts with a sliver of the problem growing at the core of community.

The reality is that medical care has its hands full dealing with downstream problems. Disease is changing and treatment complicating faster than medicine can learn and adapt. All of this consumes financial resources and drains vital energy from everyday practitioners at the point of care.

The problem is huge and there will never be enough slack within healthcare to solve the problem because it sits outside its primary mission and core expertise. But, the bigger obstacle is that the complexity and dynamics at the core of community require a different approach.

A sustainable solution needs new ways of thinking.

Healthcare has done important things using best practices and population-based statistical evidence. This is possible because many systems within healthcare are composed of stable materials connected through predictable relationships. No matter how complicated these become, their parts and relationships don’t develop minds of their own or initiate self-organizing complex system behavior.

In a complicated system, it is safe to focus on the parts. The fact that the parts and relationships are stable means that improving a single part can lead to predictable results. But complexity develops when the parts and relationships become interactive and dynamic - limiting our ability to see long-term consequences of our actions.

A community system is dominated by relationships, and how it will react depends on the state of each part and the state of the connecting relationships when the change is made. Our inability to predict a specific result is due to our inability to know the state of the surrounding parts and relationships.

Changes we introduce may therefore not result in the outcomes we want. We need to understand and manage the relationships that control system behavior. This means using electronic information networks to guide the complex human network toward a better future.

Core community services lack effective system integration.

When we look at the structure of community services, the organization of the solution doesn’t match the nature of the problem. This is both the core of our problem and the path to something better.

Derek Cabrera, a system scientist from Cornell University College of Human Ecology notes that, “All problems arise from the mismatch between how real systems work, and how we think they work.” Our work trying to make things better, isn’t working the way we think it is.

Government agencies are focused on individual behavior and the limits necessary for a civil society. They create complicated sets of law and regulations which requires a rigid hierarchical bureaucracy to manage. This is a focus on the parts appropriate for a stable environment, but poorly applied to a dynamic environment that is dominated by relationships.

Community not-for-profits have a different problem. They work independently and are guided by self-described missions focused on a single part of the multi-dimensional problem. Competition for funding coupled with the prioritization of programs over infrastructure limits the development of system integration that might link these nimbler actors into a comprehensive solution. Because complex societal problems adapt to resist change, they persist. Multiple providers acting independently cannot change the complex behavior of the whole.

Success depends on understanding and managing relationships.

The state of its relationships, not its individuals, is the principal factor in the behavior of a community system. Information, energy and events flowing through connections create the dynamic environment we live in. These connections form circuits following electricity-like rules: feedback can amplify, attenuate or transform; resonance can efficiently transport ideas, success or failure around the world.

Community is the primary source of capable people; the root of everything we value. High-performance electronic networks can help us better understand the nature of community and give us the means to maximize community output by tuning the circuits that drive its behavior.

But we are way behind the curve. Healthcare and community services are disconnected and working in isolation. In Salem, an education and community service collaborative is working to implement the kind of adaptive integration best suited to solving problems in the complex system of the community - a model directly applicable to social determinants of health.