Understanding Patients’ Health Through Social Factors and Habits at Home

At home, we are our whole selves. At a hospital, we might barely be half.  

To provide the most comprehensive and high-quality care that treats the whole person we must focus on elements of care that are usually not visible from within hospital walls.  

The most important way Contessa addresses these social determinants of health is the setting of care—the home. The home environment expands providers’ ability to interact with patients and better understand their health behaviors. 

It may seem obvious that providing care in the home gives providers a better window into their patients’ lives. But what might be less obvious is that ultimately, health outcomes are determined more by social factors and less by clinical care than most think. In other words, there are many elements that affect long term patient outcomes beyond what we can do with a pill, a needle, or a stethoscope.  

Some of these often overlooked or under-prioritized factors include: a patient’s diet, sleep patterns, habits, substance use, physical safety, family, infrastructure, support network, education, and many more. Although treatment plans for the average patient today might be designed to intervene in a few of these factors, there are usually opportunities to make them more holistic.  

The Role of Health Literacy

Often, a key to successfully addressing these factors is focusing on improving health literacy, ideally in the environment that makes people feel most comfortable. What does that look like in action? To successfully follow treatment plans, initiate behavior change, and implement lifestyle changes, patients must first understand the importance of what their provider is telling them and why following their care plan is critical for their health and wellbeing. This means providers need to educate their patients on both clinical care and the social factors that affect it.  

• When we tell someone to take their insulin, do they understand why they need to do it and why it is important?  
• When we talk to patients about sleeping habits or substance use, they need to know how their sleep or substance behaviors interact with their treatment.  
• Perhaps one of the most common examples is when we discuss healthy eating with patients. We need to be sure that they understand what eating healthy means. But understanding what it means is only the first step. For those in food deserts, finding healthy food is the underlying challenge to healthy eating. When reasonably priced fresh groceries are not easily accessible, walking two blocks to the nearest fast-food restaurant is the best—and sometimes only—choice.  

The ability to observe, identify, and call attention to a need for intervention with issues like these helps create a platform for better outcomes in the long run. 

To achieve this, these types of conversations between providers, patients and families are best received in patients’ homes. In the hospital, it is easy to feel scared, confused, and lost. It is just as difficult to listen to and process complex health information, important instructions, or difficult news. When people are in their homes, they feel more empowered, open, and willing to engage. This gives them greater ownership over both the process, and the most important part of it: their own health.  

People live their lives at home—not at the hospital. Understanding a patient as a whole person requires understanding how they live at home. Many health disparities are explained by just how differently people live in their homes, schools, parks, and communities. Although we spend a lot of time making sure people are treated equally within the health system, once they leave, health equity in everyday life is elusive. It’s time we tackle equal treatment beyond hospital walls.  

The Big Picture

A key step toward making real change happen in healthcare is to pay attention to and understand the social determinants at play. That’s where our model gives us an advantage. Because of the pioneering way Contessa delivers care, we have a tremendous opportunity to impact this fundamental piece of healthcare on a large scale, and right in patients’ homes. By delivering care where people live, we have a unique opportunity to gain valuable insight into each patient’s real-world social determinants of health, in real time. 

Additionally, becoming part of Amedisys has broadened our capability to address social determinants of health on a larger scale. The partnership has brought us the additional support of extensive resources and people such as social workers and community health workers who have expertise in engaging with patients in their home and community contexts. They provide crucial insights and help us better understand areas of opportunity, as well as what specific support some groups of patients need. 

Once we create that deep understanding of social determinants, the next step is leveraging tools and technology to help us identify, comprehend, and implement targeted support measures that tackle the most important issues affecting the communities we serve. This is a work in progress, and we all have a role to play in comprehensively addressing this gap in our social fabric. We definitely look to the future with possibility and promise.