Addressing Social Determinants of Health in Kidney Care

The past few months have been a whirlwind for the healthcare industry, just like the rest of the world. The Coronavirus pandemic and the death of George Floyd have turned our realities upside-down, and they both awaken us to a similar reality: every day, countless Americans are being left behind by flaws in our systems — systems like healthcare.

Whether because of their skin color, their education level, their neighborhood, or their mental health condition, not everyone is being given equal opportunities to succeed. Simply put, we have to do better.

Social Determinants of Health

We’re taught that medical problems must all have a medical fix, but that’s only part of the picture.

Research shows that patient behavior and “social determinants of health” drive more than 80% of health outcomes[LF1] , especially in our most vulnerable and marginalized populations. For decades, the healthcare community has been focused on medical problems, but those only account for up to 20% of modifiable contributors to improved health outcomes.

So what are social determinants of health? Let’s think through an everyday example. A patient visits the clinic showing symptoms consistent with a common disease. Staff get the patient checked in, take her vitals, and record her symptoms. After a while, the doctor comes in, reviews the information, performs an exam, and makes a diagnosis.

“Don’t worry, we’ll take care of you,” the doctor says. “We need to get you on a prescription right away, and you’ll be feeling better soon. You’ll be fine as long as you stay on your medication. It’s a very simple fix.”

At the surface level, it does indeed sound like a “simple fix,” but let’s look at a few social factors that could seriously affect our patient’s results…

  • Income: Does the patient have the funds and insurance required to purchase medication?
  • Transportation: Does the patient have access to transportation to get to the pharmacy?
  • Mental Health: Is the patient mentally sound enough to follow through with their prescription and remember to take their medication every day?
  • Language: Did the patient understand the instructions, and will they be able to communicate effectively with the pharmacy?
  • Health Literacy: Does the patient really understand their diagnosis? Do they know additional warning signs to look out for? Are they aware of other dietary and lifestyle changes that could help them improve their condition?
  • Environment: Is the patient going home to physical, mental, or emotional conditions that could be making their condition worse?

As you can imagine, all these social determinants play a big role in health outcomes. Keeping up with a prescription might seem quite manageable to a stable middle-class family, but what about a low-income single mother without transportation? Or a senior with mobility issues who is beginning to show signs of dementia?

Empowering Patients to Take Control of Their Own Healthcare

When it comes to social determinants of health, we tend to think, “that’s not my job.” But then whose job is it? What if we simply took a step back and had a conversation? What if we made room to share stories, ask questions, and listen to people?

By empowering patients, we can once again see patients as people instead of focusing on their disease. It is important to realize that the people with the problem must be part of the solution.

Empowering patients is also not a “hand out.” With coaching, training, tools, and resources, we can give the patient accountability with lasting, long-term benefits. Here are a few practical ways that we address social determinants within our Empowered Kidney Care model:

  • Control: We help inform, educate, and involve patients, empowering them to take control of their own health. We help create a level playing field by making sure all patients know what’s going on and understand the path to wellness. The educational background of our patients varies widely, but we can empower them all with knowledge and respect.
  • Collaboration: We help staff members become mentors and coaches, working together with patients in a partnership towards better health. Underserved patients often feel like they are a burden dependent on others, but they will rise to the occasion when you make them feel like they are part of the solution.
  • Culture: We help create cultures of mutual trust, earned by listening, sharing stories, and building relationships. When we engage patients with focused questions, we can get insights into their personality or external social factors. And don’t just talk; listen! We should all actively listen to our patients’ stories and pay attention to sub-context. Listen for “me too” moments in which you can connect around shared interests or experiences. Social differences can create barriers, but empathy builds trust.
  • Community: We help create communities where everyone is working together. We all come from different backgrounds, but staff and patients alike become united when they focus on serving each other and accomplishing a common goal.

World-Class Tools and Resources

Empowered Kidney Care has also joined forces with several respected partners to provide additional tools both for patients and healthcare providers.

  • Understanding Social Risk Factors: To create health equality, we must first understand the unique factors at play in individual communities. We provide data and analytics through Socially Determined to help understand social risk factors like financial strain, food insecurity, COVID-19 vulnerability, and more. By targeting locally specific pain points, we can apply relationship-based frameworks that leverage existing infrastructure and change the game. Learn more at
  • Improving Health Literacy: We can create powerful automated content calendars to deliver world-class health literacy to patients in real time. Healthline is an incredible online tool that gives us the ability to text or email patients with useful information customized for the specific step in their healthcare journey — all at an accessible 8th grade reading and comprehension level. Learn more at

A Surprise Benefit of Telehealth

When it comes to social determinants, I also see an unexpected benefit of telehealth as well. You learn a lot about a person when you meet them in their native environment. While on a video chat, you get a peek into their living conditions.

You might be interrupted by a pet or a family member, which gives you additional insights into the physical and emotional factors at home. The patient might be excited to tell you a story about their cat, their kid, or the painting on the wall. All of a sudden, you’re building a real bond and a relationship of trust.

Whether you’re meeting with a patient on your turf or theirs, the concept is the same. Take a moment to ask about their life and actively listen to what they have to say. Meet them where they are.

It’s Time to Revolutionize Kidney Care

Wherever you are and whomever you serve, your practice is affected by social determinants of health! Now more than ever, headlines around the country are illuminating this fact, and it’s critical that we keep this momentum.

The world simply won’t be the same after the pandemic is over. We have to start asking the right questions and developing smart solutions now.

Dr. Richard Gibney, Empowered Kidney Care P.C.

Dr. Richard Gibney

Dr. Richard Gibney has been in the kidney care industry for over four decades. Like many nephrologists (kidney specialists) he simply didn’t know that there were alternatives to the status quo. In 2006, a partnership with the Institute for Healthcare Improvement (IHI) inspired him to innovate. Years later, his eyes were opened by a visit about an acclaimed dialysis program in Jonkoping, Sweden. Over a four year period, Dr. Gibney led the successful transformation of 11 dialysis units in central Texas to an empowered model, serving over 500 patients with exceptional results. Staff and patients were extremely satisfied, and mortality and hospitalizations were cut in half. Today, Dr. Gibney and his specialized team of doctors, nurses, and technicians help others achieve the same empowered results.