A Study of Care Gaps in the Treatment of Diabetic Patients: Leveraging SDOH in a Family Medicine Clinic

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Identifying patient vulnerability is increasingly recognized as important in the study of population health and disease outcomes. Social vulnerability is a risk factor for developing diabetes and has a direct impact on outcomes. Diabetes and other chronic illnesses are an increasing burden on the healthcare system and by some estimates chronic illness account for more than $800 million annually. While the American healthcare system focuses on the downstream outcomes there is a need to give greater consideration to upstream issues in healthcare such as Social Determinants of Health (SDOH). The evidence suggests that there needs to be further integration of SDOH into routine primary care practice. This study looked at SDOH in a community-based Family Medicine clinic in South Philadelphia. Over an 8-month period SDOH were assessed by performing PRAPARE surveys on all diabetic patients seen in the clinic. A total of 77 surveys were completed. Both demographic and quality metric data were mined from the EHR on patients surveyed. Results of the study supported a positive relationship between SDOH factors and the current state of disease in the patients surveyed. Patients with a higher self-reported level of stress were more likely to have poorer glycemic control at statistically significant levels. Barriers that currently exist to SDOH assessment becoming a regular part of the Family Medicine assessment patients are examined. Integration of SDOH tools and resources into the EHR is explored as well as the importance of team building.



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