Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age (U.S. Department of Health and Human Services, n.d.). These environmental conditions affect a wide range of health, functioning, and quality-of-life (QoL) factors (Centers for Disease Control and Prevention, 2021). SDOH are key considerations in health, wellness, and ultimately a person's ability to recover from conditions frequently seen in home healthcare (HHC). Five key domains within the context of SDOH have been outlined in Healthy People 2030: 1) healthcare access and quality, 2) education access and quality, 3) social and community context, 4) economic stability, and 5) neighborhood and built environments (U.S. Department of Health and Human Services, n.d.). The complex relationship of SDOH to a person's health and the association with health equity require broad reaching and interconnecting mitigation initiatives from healthcare, public health, and governmental sectors. HHC therapists are among the important contributors to change as they have a vital role in evaluating and remediating factors that could improve the conditions in which a patient lives, thereby mitigating health risks and optimizing functional ability and QoL. This column recommends assessment tools useful in identifying health disparity risks, provides examples of patient-centered solutions that can be employed, and advocates for the HHC therapist's role as a change agent for health equity.

Although access to quality healthcare is indeed an important aspect of health, an individual's physical environment, health behaviors (e.g., physical activity, diet, and tobacco use), and socioeconomic factors (e.g., family support, community safety, economic factors) all play important roles in health. Approximately 80% of a person's health is impacted by things outside of the healthcare system (Neighborhood Outreach Access to Health, n.d.).

Emphasis on respectful tones, cultural humility, and intention to build trust among all individuals is foundational to a broad reaching approach which addresses the unique needs of each person. However, variations among populations based on age, race, and economics can contribute to actual health disparities which are defined as differences in overall health or unequal burden of disease and/or health outcomes between populations (Penn Medicine: The Center for Health Equity Advancement, 2020). Clinical decision aids, practice guidelines, and other tools are available for use in screening and assessing SDOH in day-to-day clinical practice (Andermann, 2016). Two such SDOH assessment resources are the National Association of Community Health Centers PRAPARE screening tool (National Association of Community Health Centers, 2022) and the Health Leads Social Needs Screening Toolkit (Health Leads, 2018). Both tools contain questions aimed at gaining insight into food insecurity, housing stability, and transportation barriers which could be used to direct person-centered education and referrals.

Specifically, the PRAPARE screening tool asks if [during the past year] the individual or those living with them have been unable to get food when it was needed. An affirmative response suggests a food insecurity risk. This could prompt the therapist to further assess and facilitate a referral to their agencies' medical social worker (MSW) or a dietician. Additionally, the therapist's physical assessment may provide insight into the person's physical ability to shop for food or prepare meals and then determine a plan of care to address the identified functional deficits.

The Health Leads Social Needs Screening Toolkit asks individuals if they are "worried that in the next 2 months, they may not have stable housing?" This may also suggest the need for a referral to the MSW or involvement of a community agency such as the Area Agency on Aging 1-B which is capable of delivering a wide variety of SDOH-focused services to seniors and their caregivers (Area Agency on Aging 1-B, n.d.). Furthermore, this finding could prompt an occupational or physical therapist to assess and recommend equipment and strategies to optimize safety of the physical environment which could include adding grab bars and railings in key areas of the home, identifying signs of abuse or neglect, and assuring physical readiness to respond to home emergencies including power outages or home fires.

Transportation provides a third example of how a social determinant can bring about a health disparity. The question "In the last 12 months, have you ever had to go without health care because you didn't have a way to get there?" from the Health Leads Social Screening Toolkit provides an opportunity for a therapist to begin transportation-focused conversations. The homebound criterion of many insurers to provide reimbursement for HHC further increases the likelihood of an affirmative response to questions related to transportation barriers. Even when public transportation is available in a community, a person's ability to exit the home, walk a distance to a bus or metro stop, and get on and off the transporting device all need to be considered as feasible healthcare access obstacles. Extending the view of meeting the homebound criteria beyond the threshold of a person's home and into community may better determine the scope of barriers for at-risk populations. Furthermore, telehealth services which have escalated in availability as an outcome of the COVID-19 pandemic provide growing opportunities to supplement transportation for health services; however, the digital divide continues to impose ongoing barriers to fully integrate for all.

Although many of the examples provided are interactions with an individual patient, the complexity and multifactorial nature of SDOH require approaches at many levels to fully address health disparities. Andermann (2016) suggests healthcare providers consider advocacy to improve heath equity and reduce health disparities. These actions may include: 1) advocating for hard-to-reach patient groups, 2) developing partnerships with community groups, public health organizations, and local leaders, 3) using clinical experience and research evidence to advocate for social change, 4) getting involved in community needs assessment and health planning, and 5) changing social norms through community engagement. An appreciation by HHC therapists of their vital role as change agents for health equity in individuals and communities is paramount.

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