Increasingly, health professionals are recognizing and embracing the idea that socioeconomic circumstances must be addressed in order for individuals not only to have equal access to quality health care but also to experience positive health outcomes. But how should this approach be implemented to ensure the most effective care possible?

Broadly, social determinants of health are the conditions and circumstances under which someone is born, lives, works, grows old and retires. But unless individuals are asked directly about the particulars of their home environment and everyday existence, these complicated areas of their lives can remain hidden from doctors.

“The main way we try to measure [social determinants] is by asking patients if they’re exposed to pollutants or have food insecurity or experience issues with homelessness or domestic violence,” says Karina W. Davidson, PhD, MASc, a clinical health psychologist and senior vice president of research at The Feinstein Institutes for Medical Research at Northwell Health in Long Island, New York. “There’s a long list of conditions and circumstances that can adversely impact someone’s health.”

Findings show that people who suffer economic, mental and physical challenges often have the most frequent need for high-cost care. Researchers explain that addressing such problems requires a team approach if health care systems hope to reduce disparities and improve the health of individuals in any meaningful way, researchers explain.

In 2014, the Camden Coalition, Primary Care Progress and the Association of American Medical Colleges designed a course to educate students about “hotspotting.” The term refers to the practice of identifying patterns of high use of medical services by people with complex health and socioeconomic needs. These individuals are sometimes referred to as “super-utilizers” of health care systems.

At Thomas Jefferson University in Philadelphia—one of 24 institutions across the country that implemented the course—students received training via the Student Interprofessional Hotspotting Program. Each student was assigned to a team made up of different medical professionals. In turn, each team was charged with assisting a single patient to negotiate their social problems and any other issues that they found challenging when dealing with the health care system.

In this pilot program, findings showed that the team approach closed the gap between patients and their providers, resulting in people benefiting physically, mentally and emotionally.

By screening these super-utilizers of the health care system to determine their nonmedical needs, teams found that they were able to help individuals access food and transportation, better understand medical terminology and develop more trusting relationships with medical staff. As a result, these patients’ health outcomes improved markedly.

“Health care systems are just starting to grapple with how best to address these issues for their patients,” Davidson says. “Best practices can include locating community resources and having social workers who can immediately connect a patient upon hearing about an issue so the challenge is correctly dealt with.”

This also helps people find resources they may not be aware are available. But these types of services require funding.

“The money to prevent an illness from happening and to help empower a community to move toward system-wide solutions is scarce,” Davidson says. “But there are health care systems that know it’s the right thing to do, and they’re willing to do it.”