Family Medicine · Year 3 · from Family Medicine

Case 3: Social Determinants of Health

Patient Case

Patient: Mr. Tyrone Williams Age: 54 years old Insurance: Medicaid

Clinical Scenario

Mr. Williams is a 54-year-old man with poorly controlled type 2 diabetes (HbA1c 11.2%), hypertension, and obesity. He has missed several appointments over the past year. When he does come in, his prescriptions are often not filled. Today, he presents for an urgent visit because he "doesn't feel right."

Initial Assessment

Chief Complaint: "I've been dizzy and my vision has been blurry for a couple weeks."

Vital Signs: BP 178/102, HR 88, BMI 34

Labs Obtained: HbA1c 11.8%, fasting glucose 287 mg/dL

Clinical Findings: Diabetic retinopathy on fundoscopic exam, peripheral neuropathy

Deeper History - SDOH Screening

During the visit, you use a validated SDOH screening tool (PRAPARE).

Housing:

  • "I lost my apartment 3 months ago. I've been staying with different friends and family."
  • Currently sleeping on cousin's couch
  • No permanent address

Food Security:

  • "Sometimes I run out of food before I have money to buy more." - YES
  • "I skip meals so my grandkids can eat." - YES

Transportation:

  • "I don't have a car. I take the bus but sometimes I can't afford the fare."
  • Missed last appointment because bus route changed

Medications:

  • "I can't afford all my medications. I take the diabetes one but not the blood pressure one."
  • Fills prescriptions when he can afford copays
  • Has been rationing insulin

Employment:

  • Lost job 4 months ago due to company downsizing
  • Looking for work but "hard when you don't have a permanent address"

Clinical Image

Image: Framework showing the five domains of social determinants of health: economic stability, education, healthcare access, neighborhood/built environment, and social/community context.

Image Source: Wikimedia Commons Attribution: Based on Healthy People 2030 framework, Public Domain URL: https://commons.wikimedia.org/wiki/File:SDOH_framework.png

Assessment

Medical Diagnoses:

  1. Type 2 diabetes mellitus, uncontrolled with retinopathy and neuropathy
  2. Hypertensive urgency
  3. Obesity

Social Diagnoses (ICD-10 Z codes):

  • Z59.0 - Homelessness
  • Z59.4 - Lack of adequate food
  • Z72.9 - Problem related to lifestyle (transportation barrier)
  • Z56.0 - Unemployment

Understanding the Root Cause

Mr. Williams' diabetes is not poorly controlled because he doesn't care or doesn't understand his disease. It's poorly controlled because:

  • He cannot afford his medications consistently
  • He cannot eat the regular, healthy meals required for diabetes management
  • He cannot attend appointments reliably
  • He is under enormous stress from housing instability
  • His insulin requires refrigeration, which is difficult without stable housing

Integrated Medical and Social Intervention

Medical Management:

  • Addressed hypertensive urgency (clinic observation, oral medications)
  • Adjusted diabetes regimen to more affordable options:
  • Switched from brand insulin to NPH + regular (available at $25/vial without insurance at some pharmacies)
  • Continued metformin (affordable generic)
  • Ophthalmology referral for retinopathy
  • 2-week follow-up scheduled

Social Work Referral (same-day warm handoff):

Housing Resources:

  • Emergency shelter information
  • Referral to Housing Authority for Section 8 application
  • Connected to local homeless services coordinator

Food Resources:

  • Local food bank referral
  • SNAP (food stamps) application assistance
  • Information about free meal programs

Medication Assistance:

  • Pharmaceutical patient assistance programs
  • 340B pharmacy referral (reduced-cost medications)
  • State pharmaceutical assistance program enrollment

Transportation:

  • Medical transportation benefit through Medicaid (arranged rides to appointments)
  • Information about subsidized bus passes

Employment:

  • Referral to workforce development center
  • Information about job training programs

Documentation

In the EHR:

  • Z codes documented for social diagnoses
  • Social work note attached
  • Follow-up plan includes both medical and social components
  • Care manager assigned for ongoing support

Follow-Up (6 weeks later)

Progress:

  • Staying in transitional housing with case management support
  • Receiving SNAP benefits and using food bank
  • Medications filled through patient assistance program
  • Attended ophthalmology appointment (transportation arranged)
  • HbA1c: 10.1% (improved from 11.8%)
  • BP: 144/88 (improved)
  • Taking all medications as prescribed

Ongoing Plan:

  • Continue care coordination
  • Monthly visits until stabilized
  • Working with housing case manager on permanent housing
  • Continued food bank and SNAP

Teaching Points

  1. Screen for SDOH systematically - validated tools (PRAPARE, AHC HRSN) identify needs efficiently
  1. Social factors often explain "non-compliance" - before labeling a patient as non-adherent, understand their circumstances
  1. Document social diagnoses with Z codes - enables tracking, demonstrates medical necessity, supports care coordination
  1. Build community resource connections:
  • Know your local food banks, housing services, transportation options
  • Develop relationships with community organizations
  • Use platforms like findhelp.org or Unite Us to identify resources
  1. Warm handoffs are more effective than cold referrals - introduce the patient to the social worker or care coordinator in person
  1. Social interventions are medical interventions - addressing food insecurity in a diabetic patient is as important as prescribing metformin
  1. Health equity requires addressing root causes - disparities in health outcomes are often rooted in social determinants

Key Teaching Points Summary

Quality Improvement

  • PDSA cycles: Plan (identify problem, design intervention), Do (test on small scale), Study (analyze results), Act (adopt, adapt, or abandon)
  • Root cause analysis before intervention
  • Specific, measurable aim statements
  • Multidisciplinary team involvement
  • Track process, outcome, and balancing measures

Prior Authorization and Advocacy

  • Documentation is essential: diagnoses, current medications, prior trials, guideline citations
  • Know the escalation pathway: written appeal → peer-to-peer → external review
  • Cite evidence-based guidelines
  • Document everything for patient and practice protection
  • Advocacy is a core physician responsibility

Social Determinants of Health

  • Screen systematically with validated tools
  • Social factors often explain "non-compliance"
  • Document with ICD-10 Z codes
  • Build community resource connections
  • Warm handoffs are more effective than cold referrals
  • Addressing SDOH is a medical intervention

All cases for this lecture as Markdown