GENERATIONS – Journal of the American Society on Aging

‘Individuals with chronic illness often do not make significant progress with their health conditions.’ during typical healthcare-related visits, thus increasing the risk of developing chronic condi- tions and reducing an individual’s ability to man- age these conditions, all resulting in increased healthcare utilization and costs. Many health systems lack the infrastructure and incentives to develop systematic screening and referral protocols, or to build relationships with existing community service providers. Findings from Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multi- ple Chronic Conditions , a report from Quest Diag- nostics (2018), showed that providers feel they are unable to address patients’ comprehensive needs. Providers cite limited time, while patients’ professed satisfaction with their care may mask social and behavioral risks and needs. These findings suggest that the traditional medical care model of an annual provider visit may be insuffi- cient for those with multiple chronic conditions. Findings from this study also indicated that 85 percent of providers say they were too pressed for time to address complex clinical issues, and 66 percent indicated that they do not have time to address social and behavioral issues, such as financial concerns or loneliness, that could affect their patients’ health. More than four in ten pa­ In 2016, the Affordable Health Communi- ties initiative by the U.S. Department of Health and Human Services (HHS) announced that it was awarding $157 million dollars for projects that integrated social services with healthcare. The initiative’s goal was to test whether screen- ing beneficiaries for unmet health-related social needs, and increasing their awareness about and access to community-based services, would improve quality and affordability in Medicare and Medicaid. HHS recognized that over time, unmet social needs are not detected or addressed

tients (42 percent) thought that seeing their phy- sician only one to two times per year to manage multiple conditions was “just not enough.” Social Determinants of Health Social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the set of forces and systems shaping the conditions of daily life,” according to the World Health Organization (Allen et al., 2017). Social determinants of health are indexed by factors outside of the individual, beyond genetic predis- positions and individual behaviors. They are the contexts in which individual behaviors arise. According to the National Research Coun- cil and the Institute of Medicine, the most im­ portant social factors determining health are income, accumulated wealth, education, occupa- tional characteristics, and social inequality based on race and ethnic group membership (Woolf and Laudan, 2013). These variables have direct effects on other social determinants of health such as living conditions, food security, levels of stresses and strains, social disadvantages over the life course, environmental factors that influ- ence unhealthy and healthy lifestyles, high- or low-risk health behaviors, biological outcomes through gene expression, and other connections to chronic diseases. Regarding gene expression, epigenetics refers to external modifications to DNA that turn genes “on” or “off.” Epigenetic change is a regular and natural occurrence, but also can be influenced by several factors including the environment, lifestyle, and disease state. A wide variety of ill- nesses, behaviors, and other health indicators have some level of evidence linking them with epigenetic changes, including cancer, cognitive dysfunction, and respiratory, cardiovascular, reproductive, autoimmune, and neurobehavioral illnesses (Weinhold, 2006). The social context of a person’s life, origi- nating in childhood and accumulating over the life course, determines their risk of exposure, degree of susceptibility, and the course and out-

14 | Spring 2019

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