The causes behind the causes

PHOTOGRAPHY BY CARY NORTON

Excerpted from page 18 of the November/December 2022 edition of AOA Focus.

Everyone—optometry students, doctors of optometry, educators and volunteers—grabs something to carry into the Medical Outreach Ministries free clinic in Montgomery, Alabama, on a Saturday in July. Supplies from eyedrops to screwdrivers and cases carrying hand-held slit lamps, portable fundus cameras and binocular indirect ophthalmoscopy are carried inside. By 9:30 a.m., the mobile eye clinic is up and running.

Given their marching orders, third-year optometry students from the University of Alabama at Birmingham (UAB) School of Optometry fan out and patient flow is soon steady as student captains take the lead. Patients check in at the front desk and are directed down the hallway to numbered doorways. Histories are conscientiously taken. Preliminary tests are performed. Refractions are done. At the doctors’ station, Janene Sims, O.D., Ph.D., and Alexia Vaughn, O.D., M.S., MBA, review records, test results and thoughts on diagnoses. Referrals are made, prescriptions are written and some patients head to the optical area where they pick out frames for glasses to be delivered later to the Medical Outreach Ministries, which has partnered with the school of optometry for the eye clinic.

UAB’s Community Eye Care mobile clinic has seen as many as 90 patients in a single day over the course of several years, serving the public in the Birmingham area and the Alabama counties known as the Black Belt—an area in the South that is named for its dark, fertile soil and ties to cotton production. But on this mission to Montgomery, the student interns, doctors of optometry and volunteers see 55 patients. According to Dr. Sims, director of Community Eye Care, the outreach arm of UAB Eye Care, a cornucopia of eye conditions and diseases are diagnosed, including:

• Amblyopia
• Alternating exotropia
• Elevated blood pressure
• White without pressure, lattice degeneration
• Keratoconus (6 diopters of astigmatism)
• Diabetic retinopathy
• Hypertensive retinopathy
• Vitreous hemorrhage
• Various types of cataracts
• Multiple glaucoma suspects

At the UAB eye clinic in Montgomery, only two of the 55 patients seen that day had health insurance—hinting at the circumstances that may lead them to miss out on regular primary eye care, thereby putting their vision at risk, judging by the list of serious eye conditions on Dr. Sims’ list.

Upstream circumstances such as a lack of access to care can drive patients’ health status and are referred to as “social determinants of health” (SDOH). The Centers for Disease Control and Prevention (CDC) define SDOH as the “conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes.”

According to the CDC’s Healthy People 2030 initiative, SDOH is broken into five areas:

• Health care access and quality—access to primary care, health insurance coverage and health literacy.
• Education access and quality—education attainment, language and literacy, early childhood education and development.
• Economic stability—poverty, employment, food and nutrition insecurity, and housing stability.
• Social and community context—community cohesion, civic participation, discrimination, workplace conditions and incarceration.
• Neighborhood and built environment—crime and violence, quality of housing, access to transportation, availability of healthy foods and air/water quality.

In a 2016 study in the American Journal of Preventive Medicine, researchers considered county health rankings and found that 40% of modifiable determinants of health were attributable to social and economic factors, 30% to health behaviors, 20% to clinical care and 10% to physical environmental factors.

“Health care is necessary but not sufficient for health; we must train our health-focused professionals on what truly impacts health and on how to invest in the tools, partnerships, programs and policies necessary to combat social economic iniquities,” the study’s authors say.

SDOH: A change of mindset?

SDOH is hardly a new concept to health care providers, but efforts to take it from ideation to actuality are steadily emerging, though not without fits and starts.

As for the fits: The authors of “Social Determinants of Health Data Availability for Patients with Eye Conditions” found “low” compliance by providers and “highly variable” entry of SDOH-related data into a national database and local electronic health records (EHRs).

“Although the SDOH easily resonate for clinicians, given their intuitive recognition that health outcomes are affected by patients’ conditions outside the clinical walls, clinicians may raise several concerns about involvement in the SDOH,” the National Academy of Medicine says in a 2017 discussion paper. “First, they realize that this is not their domain of expertise or current accountability. Second, some are worried that health care systems already have enough to address and should not play a role in efforts to mitigate or improve the SDOH. Third, they express concern about the limited evidence of effectiveness of interventions by health care on the SDOH.

“There is a viewpoint, however, for health care to find its role in population health, and some providers believe there is enough science to support integration of SDOH into health care and are pursuing evidence-informed interventions with community partners.”

The authors of a  Public Health Reports article in 2014 write: “Despite challenges, controversies and unanswered questions, the tremendous advances in knowledge that have occurred in the past 25 years leave little room for doubt that social factors are powerful determinants of health.”

Doctors of optometry are already taking SDOH into consideration informally as they provide care, says Zachary McCarty, O.D., chair of the AOA’s Quality Improvement and Data Committee, who practices in Tennessee. For instance, patient intake forms may capture some SDOH-type information voluntarily provided by patients.

Yet, doctors of optometry may be asked or required in the future to be more intentional—to educate themselves on the subject and formally incorporate SDOH into their practices’ EHRs or more, especially if it means improving the care of patients, Dr. McCarty says.

“It’s an adjustment to our established mindset about how to deliver the best care possible,” he says of SDOH. “If we can change our thinking—so we truly evaluate each patient and their circumstances—it will make all of us better physicians and elevate the care that we provide.

“For instance, how can we convince a patient to buy and take their glaucoma medication if they can’t afford food?” he says. “How about getting the patient to their follow-up appointments if they don’t have reliable transportation? If a patient is depressed, might they choose to ignore treatment advice? Knowing the answer to these questions helps to go beyond basic history that we collect and determine how to better tailor our care for the individual and their life circumstances.”

SDOH: Catching on

And now, the starts.

The Office of the National Coordinator for Health Information Technology (ONC-HIT) has identified the use and interoperability of SDOH as a priority, specifically standards and data, infrastructure, policy, and implementation. The standardization of data collection and sharing will enable better tracking, analysis and use of patient information across health care organizations and social service agencies. For instance, though some EHRs do have fields for questions about a patient’s housing and if they experience food insecurity, the questions are by no means standard in wording.

Under the Department of Health and Human Services, the ONC is the primary federal agency designated to coordinate efforts nationwide to advance health IT.

“The ONC-HIT is attempting to drive adoption of these questions into EHRs by codifying them into the U.S. Core Data for Interoperability (USCDI),” Dr. McCarty says. “As such, more EHRs should begin to include these questions into their programming for data collection. The big question: Are doctors utilizing this feature to collect the data and then use the data to effect change in health care? The hope is that by including these questions and collecting this data, health care can be delivered in a more equitable fashion to the population.”

When the National Eye Institute rolled out its strategic plan for 2021-2025 in 2021, SDOH was called out as a “key priority” and referenced about 10 times in the report, including a “bold” prediction for the future regarding research goals that were “potentially within reach”:

No. 16: “Research incorporating social determinants of health will lead to new strategies for improving eye and vision disease prevention behaviors such as compliance with eye exams and medications, particularly in populations that experience health disparities.”

In January 2021, the Centers for Medicare & Medicaid Services (CMS) issued guidance to state health officials designed to incentivize the adoption of strategies that address SDOH in Medicaid and the Children’s Health Insurance Program (CHIP), in order to reduce costs and increase patient outcomes.

“It is estimated that SDOH now represent between 40% and 50% of the cost structure of Medicare and Medicaid,” says an article published in Population Health Management in June 2022.

Not only can SDOH data reflect patients’ risk factors and the nonmedical needs affecting their health status, but it also can support care coordination between health care and social services providers who can partner to address patients’ needs. Take for example the state of North Carolina’s Healthy Opportunities Pilots program. It’s part of the state’s transformation from Medicaid fee-for-service to managed care—being paid for with $650 million in funding authorized under a Medicaid 1115 waiver to support capacity building and cover the costs of nonmedical services such as inspections for housing safety and quality, violence intervention services and diabetes prevention.

Launched in 2019 in each of North Carolina’s 100 counties, NCCARE360 describes itself as “the first statewide network that unites health care and human services organizations with a shared technology that enables a coordinated, community-oriented, person-centered approach for delivering care in North Carolina. NCCARE360 helps providers electronically connect those with identified needs to community resources and allow for feedback and follow up.”

Says Rebecca Wartman, O.D., AOA Coding and Reimbursement Committee chair who practices in North Carolina and lectures extensively to doctors of optometry about the impact of SDOH: “As a provider, I can refer patients with social service needs through that loop, and I will get feedback if the patients took advantage of it.”

According to its website, NCCARE360 has a database of over 2,500 social service agencies and 42,000 people had used the network as of Dec. 1, 2021. Could NCCARE360 be a model for other states? Several are already involved. For instance, the states of California ($1.5 billion) and Washington ($994 million) have been granted authority by Medicaid to develop programs that coordinate care among health care providers and social services that address SDOH.

Coding SDOH

Despite underreporting in EHRs, SDOH-related questions are increasingly showing up there along with the usual patient histories, vital signs, lab results and medication orders, say the authors of an article published in November 2020 in the Journal of the American Medical Informatics Association, which noted that 9 in 10 office-based physicians have adopted EHRs. “The digitization of clinical records presents a new opportunity to integrate SDOH into electronic health records to enhance care delivery and population health,” they write.

Although the CMS does not reimburse doctors for recording socioeconomic factors influencing health status, it encourages providers to track the data in their electronic health records. Those factors are currently listed under ICD-10 codes within the Z category between Z55-Z65.

Effective October 2022, codes for inadequate housing and food insecurity were expanded.

“And for 2023, they are going to add a few more that relate to some transportation insecurity, some financial insecurity and some maternal hardship; at least that was in the tentative draft,” Dr. Wartman says.

“To my knowledge, for most of the insurers, reporting these codes is generally optional,” she adds. “However, I know that at least in North Carolina, Medicaid is doing a pilot study where they want providers to start coding them, even though they are not going to pay extra unless you are a special advanced clinical care provider.”

Front lines of eye care

When the Michigan Department of Health and Human Services released its “Social Determinants of Health Strategy: Michigan’s Roadmap to Healthy Communities” for 2022-2024, lead exposure in homes and drinking water got attention.

Eight years ago, Flint, Michigan, burst into national headlines when the city’s lead-contaminated drinking water was detected in homes. The water was brought there by corrosive pipes. Nina Glauch, O.D., practices at East Michigan Eye Center in Flint. The practice serves a “very diverse” population and Dr. Glauch wouldn’t have it any other way. She is the only doctor of optometry on the staff, along with four ophthalmologists. Two of the four are retinal specialists, brought on “because we have so much disease”—diseases such as diabetes and macular degeneration, she says.

While the water crisis and the scandal that followed took a physical and mental toll on residents there, lead exposure is not the only health challenge for the community, observes Dr. Glauch, who commutes 45 minutes twice a day to practice in Flint, drawn by the challenge of practicing public health.

Say the authors of “The Flint Water Crisis: A Coordinated Public Health Emergency Response and Recovery Initiative” published in the Journal of Public Health Management & Practice in 2019: “Once an industrial center with the highest median income for young workers in the nation, Flint had been in crisis for decades due to multiple socioeconomic factors such as disinvestment, unemployment, racism, poverty, violence, food insecurity and depopulation … In addition, just as in many low-income and minority urban centers, children in Flint were already at increased risk for lead exposure because of older and deteriorated housing stock and poor nutrition.”

“We see it,” says Dr. Glauch, who marvels about the resilience of Flint residents and dedicates herself to educating patients on continuing their care post-visit. “We literally see the impact of their struggle. I see it as a symptom of a bigger issue that can’t be separated out. They are all compounded and interlinked.”

Even with the complexities, Dr. Glauch likes practicing where she believes she can make a difference. She speaks about two patients with particularly painful and stubborn cases of iritis. One patient had a history of ankylosing spondylitis, with one inflammatory marker that “was the highest we had ever seen” and was not being managed at the time by a provider. (Ankylosing spondylitis is a disease that primarily affects the spine. Among its symptoms is iritis.)

The second patient saw her iritis return each time an attempt was made to taper off her medication and had highly inflammatory markers. After testing, both patients were referred to rheumatologists; however, neither could get appointments for months due to a limited number of providers in the community and insurance limitations. It’s not unusual to have the severity of patients’ conditions fueled by such factors as a lack of insurance, access to doctors or transportation, she says.

“When you have an eye issue that stems from a systemic issue, you have to solve what is wrong systematically to be effective at treating the eye condition.” Dr. Glauch says. “I like answers and long-term solutions for patients.”

Hindsight 20/20

A few days later, Dr. Sims reflects on the Montgomery clinic. Beyond providing eye care to the underserved, one of the goals of the mission trip to the Black Belt was to help students appreciate that not every patient will have regular access to care or can afford the “latest and greatest drugs. So, what do they do then?” she says.

Dr. Sims recalls the young man whose “blood pressure was through the roof” and he was not yet 20 years old. He was told, “If we are seeing changes in your blood pressure, then your blood pressure is having some effect on the back of your eye. Your overall health would be better if your blood pressure was better controlled. So, it’s important that you take your medicine. Also, take this letter to your primary care physician.”

“What we can do is educate and refer,” she adds. “We are doing our part to assess their overall health, and the eyes are a great way to do that because we’re able to look at the blood vessels in their eyes. And if it’s going on in the eye, it’s going on everywhere else in their bodies. If we inform them of their condition that they didn’t know about and try to get them services so they can get taken care of, that’s all we can do. My goal is to get more students interested in doing mission work and realizing that mission work doesn’t have to be overseas. There are a lot of people in need right here whom you could serve.”

Being a better doctor

• The state of Alabama reports that 63 of its 67 counties hold medically underserved designations. In the state:
• 5% of adults in a 2019 survey said they had been diagnosed with high blood pressure or hypertension by their doctors.
• 1 in 5 adults and 1 in 4 children encounter food insecurity.
• An estimated 34,668 adults are diagnosed with diabetes every year, the American Diabetes Association reported in 2021.

Born in Alabama, third-year UAB optometry student Dustin Scott often visited relatives in the nearby community of York, population 2,400. Located in western Alabama, York sits in Sumter County with a median annual household income of about $35,000. Like Montgomery, it is in the Black Belt region and its population is 87% African American.

Scott has fond memories of visiting relatives in York. It’s why he worked so hard to bring Community Eye Care there in September.

“It’s partly why I feel so strongly about bringing an eye clinic there because of the extreme lack of not only eye health resources, but health clinics there in general,” Scott says. “A lot of people drive from York to Meridian, Mississippi, just to see doctors there. For senior citizens, a 1-hour, 10-minute drive round trip is a lot, and coordinating appointment times and follow-up schedules is challenging. That leads to people missing appointments or not going to the doctor at all. They don’t realize there are insidious diseases such as glaucoma that can take vision away without proper treatment. I hope this clinic serves as an informational opportunity to educate patients on the importance of routine eye care.

“I think to be a good doctor you must be aware of people’s culture, health literacy and financial situations,” he adds. “I’ve learned that the best care isn’t one-size-fits-all—it’s tailored to each individual that you see. I think the Black Belt is so important in teaching someone who may not be from an area like York, Alabama, to be a better doctor to a wider demographic.”