Commentary Highlights VA's Progress and Next Steps in Incorporating Social Determinants of Health
Social factors, such as poverty, discrimination, physical environments, and violence, sometimes referred to as "social determinants of health," have stronger relations with individuals' health and wellness than does healthcare. Thus, in 2014 the Institute of Medicine issued landmark recommendations for collecting and documenting social and behavioral factors in patient electronic health records (EHR). Providing care for more than 6.3 million Veterans, whose medical information is retained in electronic health records, VA has been at the forefront of screening for several social factors. This commentary outlines the recommendations of an inter-professional workgroup of 26 VA and non-VA health services researchers, Veterans who use VA care, as well as leaders from several VA offices and centers, brought together by HSR&D to identify challenges and opportunities for addressing social factors in the VA healthcare system.
One of VA’s earliest universal clinical screens was to assess experiences of sexual harassment or assault during military service (military sexual trauma; MST), followed by universal screening for housing instability, and, more recently, intimate partner violence and food insecurity. VA also operates several programs to address social factors such as justice involvement and unemployment. Further, VA’s current “whole health” initiative strives to comprehensively integrate social factors and person-driven goals for wellness. Despite such progress, challenges remain (i.e., linking Veterans to community resources to address unmet needs, data sharing between VA and community partners) and new ones emerge. Workgroup discussions yielded three major themes to better address social factors: 1) collecting and using data on social factors, 2) understanding the complexity of co-occurring social factors, and 3) building models and an evidence base for interventions to address social factors in VA.
From these emergent themes, workgroup participants offered strategies to enhance VA’s efforts in social determinants of health. For example, when VA implements new screens and services related to social factors, evaluation plans should be designed before the implementation. Engaging health services researchers early in the process is crucial for refining evaluation design, data elements, and outcomes. HSR&D has developed innovative programs aimed at these efforts, such as the Researchers and Evaluators in Residence program, in which health services researchers spend an allotted time with VA clinical offices for on-the-ground experience in the policy- and process-levels of the healthcare system. Another program is the Quality Enhancement Research Initiative (QuERI)—VA’s engine for translating evidence into healthcare practice and implementation. VA also continues to prioritize Veteran engagement in research activities, as well as partnerships with community agencies. The breadth of data and the innovative environment bode well for VA to be a major national laboratory, liaison, and leader in navigating the challenges around the integration of social factors into healthcare.
Dr. Blosnich was supported by an HSR&D Career Development Award. Drs. Blosnich, Dichter, and Hausmann are part of HSR&D’s Center for Health Equity Research and Promotion (CHERP), Pittsburgh and Philadelphia, PA.
Blosnich JR, Dichter ME, Gurewich D, et al. Health Services Research and Social Determinants of Health in the Nation’s Largest Integrated Healthcare System: Steps and Leaps in the Veterans Health Administration. Commentary. Military Medicine. June 27, 2020; Epub ahead of print.