It’s the role of the Social Services team to get to the heart of a patient’s specific social drivers of health, acting as a third pillar of support along with medical and behavioral health staff. Social Services support is available to established patients who have seen a provider in the past year and are otherwise eligible for OneWorld Services. Sometimes Social Services staff begin providing support while meeting with the patient, as in the above example. At other times, they may work behind the scenes to identify community resources and follow up with a call. Depending on the situation, Behavioral Health staff might arrange to work with a patient over time – or may only have a brief session with them alongside a primary care visit. Behavioral Health Therapist Karla Deacon, LMHP, LADC, said these brief sessions can include discussions about the mind-body connection, or how current stressors might be expressed physically. For example, a patient who has been suffering from headaches might share that their spouse has lost a job, which opens a discussion on managing anxiety. But sometimes patients are living with ongoing effects of systemic or political realities – those “upstream” social drivers of health that lead to the worst outcomes for the least powerful. Deacon said many OneWorld patients experience the complexity of having been forced to leave their home country in order to survive, while enduring the separation from loved ones who remain. They may send money back to support family members, while living in poverty here.
Social Worker Jair Alvarez speaks with patients to learn about their social determinants of health.
Understanding that big picture helps a patient’s care team provide the right resources. “Many patients are depressed because the finance, because the food,
because the housing, and many external factors that are related with resources in the community,” said Longfellow Marquez, LIMHP, LMHP, LADC, Behavioral Health Therapist and Licensed Alcohol and Drug Counselor Trainer. “That’s also the component for the holistic treatment that we can provide to the patient.”
Longfellow Marquez, LIMHP, LMHP, LADC
Behavioral Health Therapist and Licensed Alcohol and Drug Counselor Trainer
Social determinants of health Many areas of life can impact health and well-being, including access to health care, housing, healthy food and transportation and other conditions present where a person lives or was born. These areas may be referred to as social determinants of health or social drivers of health. The National Association of Community Health Centers uses the term “drivers” rather than “determinants,” as a reminder that inequitable conditions do not have to stay that way - reflecting the “ability for policy-makers, communities, and individuals to affect change on the factors negatively impacting health and well-being.
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