Social accountability at the micro level

Identity and demographic characteristics

Identity and demographic characteristics affect a person’s entire lived experience and health. Assess indicators such as age, race, ethnicity, religion, aboriginal status, language preference, sex, gender identity, sexual orientation, and presence of physical or mental disability. This information allows us to provide better care. For example, for a transgendered patient, determine the patient’s preferred pronoun (eg, he, she, or they). Newcomers to Canada might need to be connected to settlement services, language classes, and immigration supports. Patients with language barriers should be offered professional interpretation. For those requiring social support, case management, counseling, or mental health groups, there might be targeted agencies for referrals (eg, LGBTQ community centres, youth drop-ins, seniors’ groups).

Income

Income is the most important determinant of health, so consider screening every patient by asking, “Do you have difficulty making ends meet at the end of the month?”⁶ For those who do, assess and document specific current sources of income (eg, full- or part-time work, social assistance, Canada Pension Plan disability, tax credits). With a basic understanding of provincial, territorial, and federal income benefits, we can suggest benefits patients might be eligible for. In Ontario, “Poverty: A Clinical Tool for Primary Care Providers”⁷ summarizes this information. Similar tools exist in Manitoba⁸ and British Columbia.⁹

To access income benefits and credits, ensure your patients complete their taxes by referring them to free income tax clinics available across the country.¹⁰ It is helpful to complete forms for patients to access unclaimed benefits (eg, provincial disability, Workplace Safety and Insurance Board, Disability Tax Credit) or write letters to access discretionary benefits. Poverty can affect food security, child care, transportation, and seniors’ care, requiring referral to appropriate services (eg, food banks, meal programs, parenting centres, home care).

Education and employment

Documenting patients’ education levels can help us tailor the information we provide. For those with lower literacy, we must be careful with verbal communication and literature provided.¹¹

Knowing patients’ education levels also helps us understand their employment options and ability to navigate social services. Assess and document current employment status and precariousness (eg, part- or full-time work, contract or shift work, delays in being paid, workplace safety). We might be the first to uncover violations such as withheld pay or unsafe work practices, in which case we can encourage patients to approach a union representative or legal clinic for advice. Patients looking for work can be referred to employment counseling or resume-building or training services.

Prescription drug coverage

An important effect of income and employment status is access to drug coverage. Patients might have employer-based, public, or no coverage. If the patient has public coverage, try to prescribe medications on the formulary. If the patient has no coverage, the local pharmacy or a case worker can help determine options. Prescribing the lowest cost medications of equivalent efficacy is helpful. Some practices have compassionate funds to assist with occasional important medication costs and are moving away from dispensing samples, which have been shown to influence physician prescribing.¹²

Housing

Access to safe, affordable, stable housing is crucial to wellness. Understanding patients’ housing situations provides a bigger picture of their health.¹³ Document if they own or rent and whether they live in a room, full apartment, or house. Determine who and how many people they live with, safety, exposure to pests, the state of repair, and the relationship with the landlord. If the housing sounds unsafe or the landlord appears to be breaking the law, refer the patient to a legal clinic for advice. Individuals are considered homeless if they are “couch surfing” with friends and family, living in a shelter, or living on the street. For these patients, ensure they have information for accessing emergency shelters and are connected with a housing worker to access subsidized housing wait lists.

Social supports

The patient’s support system greatly affects health and well-being.¹⁴ This might include family members, friends, neighbours, case managers, health care providers, or community resources. If patients have specific needs (eg, child care, help with activities of daily living), clarify who supports them. Assess what external services they use (eg, drop-ins, social or mental health groups, food banks, addictions programs). Refer patients to services they might benefit from. Connecting with patients’ existing supports to share information might also help them attend appointments or follow through on recommendations.

Legal needs

We might be the first to identify an unmet need for legal services.¹⁵ If the patient has immigration needs or serious concerns with an employer, landlord, or spouse, refer him or her to a legal clinic if needed. Before assessing immigration status, assure your patient you do not disclose this information. If a patient is undergoing a refugee or humanitarian claim, a physical and mental health assessment documented by the physician can be helpful. For those facing criminal charges undergoing mental health court diversion, a letter documenting mental status and management plans can be of great assistance.

Mental illness, substance use, and trauma

While we often assess mental health and substance use, doing so thoroughly, including former experiences and family history, is crucial. Identifying substance use allows us to engage in nonjudgmental motivational interviewing and referral to harm-reduction (eg, needle exchanges, naloxone training) and outpatient or inpatient addiction services. Patients with mental illness should be offered access to counseling and psychiatric care as needed. Those with a history of crisis or suicide attempts should be given access to 24-hour support lines. Those with severe mental illness and difficulties organizing themselves should be connected with community case managers.

History of trauma is much more rarely assessed. This can include childhood abuse, physical or sexual assault, experiences of war, or incarceration. Awareness of trauma helps us understand the context of patients’ mental or physical illness and addictions, and their ability to engage in invasive medical procedures such as Pap tests. Where a trauma history exists, patients should be referred to counseling services.¹⁶ The cervical cancer diagnosis frightens Diana, and she worries about caring for her children. To support her with the emotional, psychological, and practical consequences of her diagnosis, you refer her to a peer support group for people with cancer.Having further explored social history assessment, you decide to call Diana back into your office. You learn that she is living on limited income from part-time work as a waitress, with no extended health benefits. Getting to appointments is hard owing to transportation costs. With no drug coverage, she often skips her diabetes and blood pressure pills. She lives in an apartment that she shares with her 2 children and a roommate. She feels unsafe at times because a neighbour harasses her. Her family lives out of town; she does not have many friends and has none with small children. Diana reports that her childhood was difficult, as her father drank regularly, and for the first time discloses a history of childhood sexual abuse by a relative. She tells you this is why she has always found Pap tests very difficult. You offer her the space to connect with you or the counselor at your clinic to discuss the effects this has had on her life.Based on this social history, you have Diana meet with your nurse to go through the poverty tool. Diana might be eligible for welfare based on her income, which would make her eligible for transportation and special diet funds, so you direct her to a welfare office. She is also eligible for tax credits and benefits, so you give her information for the free income tax clinic in her area. You also suggest a nearby legal clinic for support for the harassment she is facing, and suggest she talk to the pharmacist about applying for the Trillium Drug Plan. In the meantime, you review her medications to ensure she is taking the lowest cost options of equivalent efficacy. You connect her with the local parenting centre where there are activities for her children and she has the opportunity to meet other mothers for support. As Diana leaves your office she says she has never before had a doctor really ask about her life in this way and she thanks you for being so easy to talk to.