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Time for a Change of Heart

By Theresa West on 2/25/21 10:19 AM

Each February, the healthcare community rallies to raise awareness around heart healthy behaviors and the importance of regular screenings. When there isn’t a pandemic, we are doing heart walks, wearing red to work, and volunteering at screenings in our communities. Despite the strides forward in prevention and treatment, heart disease remains the leading cause of death (outside of COVID-19) among high-income countries, and is projected to be the leading cause of death worldwide by 2030.

If we want to slow or halt this trend, we need to do much more, but not more of the same. We need to expand how we think about prevention and management of heart health.

The social determinants of heart health
A growing body of evidence points to the heart health risks caused by many social determinants of health, including social isolation, poverty and economic instability, food insecurity, housing instability and household characteristics, transportation, poor access to healthcare, and lower levels of education. Even with good clinical treatment, the more social determinants of health (SDOH) issues a person has, the greater their risk of dying from a form of heart disease over the next decade.

According to the American Heart Association (AHA), many patients “must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs”. These gaps raise questions about the role healthcare and clinical practice should play in resolving the SDOH needs of patients. We also know that SDOH issues exacerbate systemic health inequities that impact access and outcomes for people of color, of different ethnicities, those living in rural areas and in economically depressed communities, among others. Terms like “digital divide” and “food deserts” have unfortunately become part of our public health lexicon.

The SDOH-heart health connection also was the subject of a recent article in Circulation that explores a best-practice model using interprofessional collaborative practices where “multiple health workers from different professional backgrounds work together with patients, families, caregivers and communities to deliver the highest quality of care”. This model calls for improved transitions of care for patients across the healthcare continuum, necessitating collaboration among multiple disciplines such as social work, public health, pharmacy, nursing, and medicine.

Pumping up collaboration
So how do we organize and mobilize the social care resources to pump up the support for those whose heart health is at risk?

Collaboratively addressing SDOH care introduces additional complexities into the existing complicated care requirements of many patients, including navigating the many state and federal patient privacy laws and regulations. This is an issue that Signify Health has been working on because it is central to our ability to drive forward our mission to help people enjoy more healthy, happy days at home.

One of the ways we are addressing this issue is by solving the connectivity problem that serves as a barrier to getting help to those who need it. We have developed a privacy-enabled collaboration platform that today is empowering cross-sector teams to document SDOH information to create longitudinal social records and to share information with each other to help meet the healthcare and social needs of their clients.

For individuals, caregivers, and families, having a connected community that shares accountability and focus means better health and a better quality of life. While progress is being made, we have an opportunity to expand the aperture of how we approach prevention and how we “treat” heart disease by recognizing and bridging the gaps in SDOH. And, in doing so, also advance our collective work to reduce health inequities.

As we observe national heart month, we salute the more than 200 social care coordinators working at Signify Health and the multitudes of community-based organizations and their thousands of dedicated team members we are working with across the country. Every day, they give their heart and best efforts to bring hope and improve the health of millions of people. If we can successfully bring together medical care with delivering on a person’s social determinants of health needs, imagine how we will transform heart disease prevention and management.


Theresa West, VP, Community Solutions, Signify Health

Topics: SDOH