AOHC Encore 2022-105: Social Determinants of Health (SODH)

105: Social Determinants of Health (SODH)

Video Transcription

a pretty small crowd today. So we have about an hour and a half. Hopefully, I'll be done about an hour and 15 minutes. And if there's any questions during this,  then please, if you want to raise your hands, we can try and deal with them as we go. And if there's any experts in social determinants of health  here, your insights, your understanding of some of these topics, feel free to chip in. I've practiced occupational medicine for 30 years.  And I work for ProMedica Health Care Systems in Toledo, Ohio. We're a large health care system that cover Northwest Ohio and Southeast Michigan. So we'll get started.  OK, I just want to start with a quote that I heard recently from a doctor, Yui Madinomo. And her comment about social determinants of health  and what she's trying to do in communities that health begins in the home and not in the clinic. And I think that's relevant to us, especially in the clinical setting,  is that we're often asked to interpret social issues, social medicine issues, in a clinical setting. And now that social determinants of health  are becoming much more in the foreground, it becomes even more of a challenge. So understanding people's lives outside our clinic setting  have just become a little bit more complicated. And we have to understand a little bit more completely. So I'm going to review the definitions of health,  social determinants of health. I'll look at some clinical issues involving and where providers are getting involved. And if you're a large system versus a small system, what  you can do to get involved. And then I'm going to look at some issues in the workplace in terms of work as a social determinant of health.  The role of the occupational safety and health professional contributing now to social determinants of health. And then just some employer viewpoints,  what they've been attempting to do under the guise of total worker health.  So I'll look at these definitions from the World Health Organization. And then the determinants of health, we sort of jump over those all the time  and go right to the social determinants of health. And then I'll look at the Healthy People 2030. And I'll use that as a frame of reference  today in terms of talking about social determinants. So the World Health Organization, this is what we learned in medical school,  is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. It was updated in 1986. So it's a resource for everyday life,  not the objective of living. Health is a positive concept, emphasizing social and personal resources, as well as physical capacities.  So if we look, what are determinants of health? This will be a little bit easier for me. When we look for determinants of health, we're looking at what the CDC now defines  as social determinants of health. Oh, I'm sorry.  So this is Healthy People 2020. I apologize. So in terms of defining the determinants of health, we have things like policymaking. We have health services, individual behaviors,  biological and genetic issues, and social factors. So in terms of social factors, here's the social determinants of health. A lot of these factors we've been  dealing with in medicine for a long time. We call them health risk appraisal. We did wellness programs. We have on-site interventions. We have health coaches.  So some of these we've sort of been addressing, especially these individual behaviors. And all these groups of determinants, they interact with each other.  So you'll see, as time goes on, the social determinants of health now have many, many individual behaviors that are being put into it as well.  Just from policymaking, it's these laws, in terms of like tobacco sales and highway safety, seat belt type laws. And then these are the individual behaviors  which we classically look for. In terms of social determinants of health, as far as the World Health Organization, this is where many people are getting started with this.  It's conditions in which people are born, grow, live, work, or age.  It's shaped by the distribution of money, power, resources, and I would say policies as well on a global and national or local levels.  We tend to interact more of a local or even a community level in terms of trying to direct policies. A lot of these policy things, if you  think of upstream versus downstream, most of the policy things are happening upstream at the source, where the source of the problem can be addressed. There's midstream.  That's what we think about our neighborhood, our communities. And then there's downstream. What we're seeing in clinic are the interventions.  And so here, this is the upstream effect. They're responsible for health inequities. And those are unfair and avoidable differences in health status.  And that's where we look at these in communities. They're non-medical factors that influence health outcomes. And more so than not, we've always  thought of them as individual determinants, whether you drink, you exercise, you smoke. So this is taking a different look at this. As far as CDC, they have their definition.  It's conditions in places where people live, work, play, learn. And their definition is different. It's not just health outcomes. It's risks. And maybe that is, if we're going  to have an intervention that's applicable from the clinical setting back, going downstream, going back to the midstream section, is how we can deal with risk in the clinic  as a preventive tool, and also how we can use community resources to address that risk. We still have to deal with outcomes. Those are usually health outcomes, but also the risk.  And the CDC, that's sort of the difference in their policy. It influences the opportunities to practice healthy behaviors, enhance or limit our abilities to live healthy lives.  And healthy for you may be different for me. What we want to do is we want to have very few barriers for you to live your view of a healthy life.  And hopefully, over time, we can all have a general concept of what healthy is, so we can re-educate ourselves on it. And then, so it's a state where we're progressing  towards health equity, where everyone, every person has the opportunity to attain their highest level of health, their highest level of health.  So here's where our framework for today is going to be Healthy People 2030. This framework is a place-based framework for five factors.  And probably everyone knows these, health care, education, social community context, economic stability, and neighborhood and building environment.  We all were introduced to social determinants of health by socioeconomic, the economic. So we think of socioeconomic status in a lot of articles and research articles,  or when we do studies in communities, we look at socioeconomic status. It's now taken a different aspect. We often report it as part of the demographics  of the research of the community. Now, it's actually in the title of the papers that we're bringing these social determinants forward.  So in terms of the impact, and these numbers keep on changing. And if you look on a global versus a US or national level, they can be all over the place.  But it accounts for about 30% to 55% of health outcomes worldwide. It's aspects of our social and economic environments that can indirectly influence an individual's health.  Remember, with social determinants of health, we don't have them. They're out there around us. So a community can have positive or negative social determinants  of health, and you can be in that community. And so the impact on you can be negative or positive, but it's not that you actually have a social determinant of health.  It's impact, so it's not an element of individual can have or not have, and it's positive or negative.  Later in the slides, I'll briefly ask a question to you, what is negative, or how do we tell when something's become positive enough type thing. Then there's social risk factors,  and they are specific adverse social conditions that are associated with poor health. Those are social isolation, housing instability, food insecurity.  These are risk factors where social determinants of health are a function. And then there's social needs. These are the actual needs that a person  has at this individual period of time. And here, food for the family, housing, transportation, and those are social needs that we apply to an individual.  We apply risk factors to the community.  And then it gets really confusing, and I have about six areas in terms of when you read the articles and start collecting information on how you're going to interpret it.  And just so you know, a recent edition, the 16th edition of Public Health and Preventive Medicine came out. I think I had the fifth edition when I was doing it,  but the 16th edition just came out. And Paula Braveman has a very good chapter on social determinants of health and probably will address these type of issues as well.  But there's a lot of confusions around social determinants health. There's a lot of different groups, clinical, non-clinical, stakeholders, government.  And they continue to add individual social determinants of health to the list. So it becomes broad and ever-changing. And sometimes that creates issues  where we're adding more and more elements that we have to consider. And sometimes we lose sight of one element because we have more elements in front of us. So this is good.  Here's a list of individual social determinants of health. This is our framework right here. So in 2007, there was a list of social determinants of health.  And they had things like biological and genetic heritage. I think that's a determinant of health in a different category, but it was in there.  And then these health services, income, those have been defined for us. But that was a list that was out in 2007. The American Academy of Family Practice,  which I'm going to refer to a little bit later, they have a broad list. And here we have gender is placed into that. Here's gender here as well.  And then we have sexual identification. And remember, it's a factor that you can't have. It's impacting you. So the definitions of what we're including.  And then between 2008, 2019, maybe 2020, other things have been added. Alcohol use. And you'll see in my own group I work with, we have these determinants in what we assess.  Child care, depression, stress, tobacco use. Two that I want to bring your attention to is broadband internet services.  And so that impacts you because your community doesn't have it. And it has to do with people seeking care who are maybe on the margin.  And I would think of rural care would just make it easier. That they don't have access to internet, not because they get a bad signal.  They don't have a signal tower to get it in the first place. And then there's the barriers of cost. And so that's a new one that's being put in there. And we'll see if that flies.  To me, it's like looking for the number 33. Once you start seeing it everywhere, now I start seeing this everywhere in terms of what could be a social determinant held for us.  And then the other one which was interesting was economic sanctions. And this is from an article from Iran where they were saying that economic sanctions were  social determinants of health. It may rightly be so. Not one that we would necessarily be doing here today. But it may be something that will show up in the future.  And then the other parts are, OK, so we have this long, growing, and broad list. And that's why I tried to stick in the framework of 2030 healthy people.  But there's interactions between each of these. So as you do something to one, you do something to others. So you can lessen or improve a social determinant of health.  Because you have a positive impact on one does not necessarily mean you can have a positive impact on the other. So just using digital connection as an example,  they're talking about improving access to health. So I could have telehealth. I could have MyCharts, those type of things showing up on my telephone.  Of course, I have to be able to have a telephone to do that, a smartphone to do that. But their interactions, which is probably good and more so now  because of COVID, is that maybe have a positive impact on education as a social determinant, on employment, on civic engagement, and housing.  And for us that not just work in clinics but in industrial sites, we saw that using telecommuting, teleworking, and not just telehealth was very beneficial during COVID.  I work with one or two company that almost have only safety sensitive jobs. And meeting that need was very challenging. And telecommuting or teleworking was very important.  Not just working from home, but being in contact with everyone in real time.  The other thing with having a long list, it decreases the enthusiasm. Because now the list and what about me, what about me, what about me, it takes a lot of lifting power.  And so sometimes the enthusiasm or the focus of the project or the intervention gets lost. And also the amount of effort we have to direct to stay focused becomes time consuming.  And that has an impact on policy level.  Remember the upstream where the biggest bang for the buck, where we can change policies, laws, and regulations. It's difficult to get politicians, stakeholders,  community programs to buy into it when I have to buy the whole package and the whole package is too large and too broad. So that creates, and so it makes it a barrier  that they hear you, but they don't want to include it into their policy making process. Remember that policy is creating biases and situations  where some communities are getting services, some communities are not. So there could be this part of the source for what's happening in our communities  as far as social determinants of health are concerned. And then here's how do we identify, this is a good question for everyone, especially anyone who's doing social determinants.  How do you determine a social determinant of health? And it's determined if a social factor impacting health is avoidable through structural changes in policies and practice.  So it isn't you just look at it. We have to apply some standard to say that really is a social determinant of health. And so if we look at some of the individual behaviors, which  is its own determinant, changing policies and practices may not always apply to them. It may be something I have to get my hands around  and that I have an influence of, but changing policies and practices may not be available. So just applying a definition, if anyone else  has a different definition, I'd gladly hear it. And so what we end up with, we end up with a dual meaning. One of the meanings is social determinants of health,  we impact in a positive or negative factor health of individuals and populations. And so we use factors to determine health. We want to impact those.  So the determinant is food insecurity. How do I take steps to do that? And the other is that we're dealing with determinants of inequalities in health.  So part of the inequalities of health is because if I live in a neighborhood that has many social determinants of health acting in a negative way, my quality of health  may be different than neighborhoods on the other side of the community.  And this is more of the political process, the community interventions, that's part of the dual meaning and messaging we get from it.  And then for those who are collecting data and interpreting data, especially in a clinic setting, we don't always have fast returns in terms of summarizing information.  And even collecting data is data for three months, one year, five year. How much data do we need to know that we're impacting? And the nice thing about industries or businesses  is that they're their own little environment. So when we implement programs, we don't have as many barriers to get a program up.  We collect information from a smaller group of people, but it's the same people, especially their year in, year out. And we're able to implement changes on sort of a quicker  return of information. When we're dealing with broad communities, usually these are smaller projects that we're measuring and saying, yes, this is a success.  And then not only is this a success, can we maintain that success or maintain that policy or practice change in the community?  And then remember, this is all from a social determinant, determinant of health. And so there's many definitions of social itself.  If you look into social medicine as its own area of study, there are many differences. There's no clear boundaries of what is social.  And we're seeing that where people are adding things like individual behaviors into these now. And remember, lots in the beginning, we learned to miss socioeconomic measures.  And really, that is 1 5th, essentially, of what the 2030, they're saying of social determinants health. But we put a lot of value or credibility  in the socioeconomic status of someone. And that gives a lot of ambiguity with this as well. And then the last thing is, these are programs that are difficult to get paid for.  It's who's going to pay for it. It's like a wellness program. We have to have a return on investment, or how do we get a return as wellness programs.  If you have employees that stay with you for 30 years, there's a good place to have a wellness program. If you have quick turnover of employees,  wellness programs just don't have as good a track record. So return on investment, how do we demonstrate that? And now in medicine, we have standards  like reduced emergency room use. So we have these standards. And again, we have to be able to demonstrate that impacting that social determinant health  is actually impacting that measure that we're looking for. So paying for it and getting feedback on its effectiveness is challenging. And it's a new field.  So we'll get some measures that we get comfortable with. So just in terms of health disparities, there are differences in health outcomes among groups of people.  They're affected by inequities. And so that's the unfair avoidables stemmed from some unavoidable barriers that stem from some injustice.  And they result from social determinants of health. So these disparities are something we are yes or no. This is the inequities on how we come up with the yes or no answer.  It's also affected by our behavior with ourselves that may lead to poor health. We want to impact that so it leads to good health as well. And so we can measure those disparities  in terms of disease and injury, disability, and mortality. And in the literature, a lot of the articles are coming out that way in terms of showing disparities that  are being looked at as the primary source. Health equity is reaching for a highest level health for all groups. And so it's not everyone has the same level.  It's that we're reaching for the highest level we can get. It's sort of like with inequities, it's not all size fit one. So it's not like if I had to ride my bike to school  and we all had to ride our bike to school, I gave everybody the same bike. That wouldn't work. What I need is the equity of people  having choices of bike that fit them to get to school. And so that's an important part of this. OK, in terms of the clinical setting and providers,  I look at some interaction between occupational medicine and workplace, some screening tools, and coding.  So when I first was introduced, I think maybe about five years ago or six years ago in terms of not in the clinic. I was dealing with industries wanting  to do wellness programs or health risk appraisals and making that meaningful, bringing on health coaches and making that meaningful. But in the clinical setting, I was sort of  presented that social determinants of health are acts or barriers or obstacles to good health. About 80% of the people, a person's health is identified by them.  So behavior, environmental, socioeconomic, we see this all the time. 20% is impacted by our clinical intervention. And then it's a source of disparities  where we have these unfair differences that are avoidable, these barriers, these inequities. And it results in inequities in many places.  And that's the other concept, is that the workplace is a place we have social determinants of health applying there. And it itself is a social determinant of health  for the larger community. And so this is trying to say, well, how are we going to impact the whole community? And also, there's a limited amount  of funds invested in to address and influence social determinants of health.  In a company program, they have a budget. And we usually get that budget approved for two or three years. And then we determine if it's a long-term solution.  Where in the community, it may be budgeted for a pilot program. And once that pilot program, we have to find other stakeholders who are invested in that.  And so this is where this sort of downstream and upstream effects of intervention come in. Upstream is the government. Downstream is what you and I, in clinic settings,  are trying to do. And we're trying to force that intervention back upstream. We're swimming against the flow to get that impact at that community.  Many of these are community or local level interventions. So helping someone identify where they can get food, helping someone identify how to get good housing,  and doing that from a clinical level. Clearly, in our clinic settings, as a provider, as a physician, we're not doing all that. But we have to collect information.  Someone has to spend time interpreting it. And we have to have those discussions and identify the resources in our clinic setting and then also in the community, if possible.  We don't follow through that it's done until the next visit. So we don't know if someone went to seek housing support or food support.  So we don't really have a good measure of that. So this is sort of my view and experience of occupational medicine. So in the course, there's four main areas.  It's administrative, wellness, clinical, and on-site. I started in clinical, in terms of our training out of hospital programs.  Sorry, which way did it go? Sorry.  And then once you get out into practice, into a hospital program that's not education-focused, then we deal more with the administrative and wellness.  And so in the 70s to 90s, we were dealing with things like physical examination, proper lifting. Drug testing came out during that time. Then we had to become MROs.  And years later, we had to be certified as MROs. And then medical surveillance has always been there. OSHA was signed in 1970 by then-President Nixon.  And those sort of standards were being applied during that period. And then in 80 to 20, we started getting on-site programs. The ergonomic interventions came out  where the packing houses were involved in a lot of that. At that time, I was working in Iowa and probably dealt with 10 or 12 packing houses and sitting on ergonomic committees  to help things happen. One of the benefits, we started getting a lot of worksite analysis during that period. And we started getting job descriptions that  were useful to us in clinic. So it wasn't that my job was that I was a truck driver. It gave me some of the variation. So if you look at a number of truck driver job descriptions,  it can vary quite a bit.  And then the safety interventions, the CPR classes and other safety interventions. And during this time, we really had a lot more interaction with on-site nurses.  At that time, they had more occupational medicine physicians on site. But with the occupational nurse, some of them may have different views, seem to really  grow in terms of an asset and a value to the work communities. And then it was, for about 10 years, it's just sort of wanting to take health risk appraisals  to the wellness type level. And we did these type of health screenings. And then we're asked for specific programs based on these screenings. We did some stress management.  And that will probably change quite a lot as we go along. And then we're always asked to do some educational activities, a back school, injury prevention type school.  But on the clinical side, during this whole time, and especially recently, we've been asked to deal with more things that are not directly work-related.  Our bread and butter musculoskeletal injury, we're now being asked about medication management. This person's come to work, and they have a cold. Can you look at them?  They don't have any health care, or they live 50 miles away. Can you do something? How can we sort of flex our ability to manage things? And we're asked for preventive services,  chronic illness management, and medication management. And that had a lot to do, I found, with health literacy in terms of not just the person, but the employers having  really no concept of what to do with this.  And they were looking for a source. A lot of the companies I deal with, we have committees to deal with this now, rather than me saying, here's my opinion.  We have some stakeholders. We have some workers. And we sort of work on making it more of a communal event. And so that's where my experience, and today in the clinics I work with,  any one patient could be fitting into this. And the actual bread and butter low back injury is still there, but not to the extent that it was before.  So then we have outside interventions influencing us. And so we have the Total Worker Health Program with NIOSH. Again, it's a, and I'll go over it briefly in a moment,  but it again has sort of shown up of how can we do some participatory interventions and see what they can do, where management has a bigger role as more of a policy procedure.  And then social determinants of health has shown up. The thing, the difference is, who owns social determinants of health? If you're going to start looking at social determinants  in your clinic, how is that happening? Is it just because you decide to do it? Or, and if you work for a health care system, you'll see we have questions about it.  But who owns that? Where with the Total Worker Health, we already have management's buy-in to do that.  I've sort of tagged social determinants of health onto that. You'll see their diagram is very similar in terms of what they're looking at. And that, for me, has been an easier way  of dealing with social determinants of health than the total health, or not having someone to own it.  So we need some screening tools. If you're in your own practice, or you're in your own business setting as an employee clinic, a health clinic on site, we don't have these tools.  Our electronic medical records, some of them may have it. Some of them may not. Some of those questions may have to be turned on. But I refer people to the American Academy  of Family Physicians. They look at five core things, housing, food, transportation, utilities, and personal safety. That's not too unlike what we think about in general.  They also look at employment, education, child care, and financial strain, which makes us fit everyone. And that's part of what's an everyone project.  It's intended to advance health equities in all communities. So for me, that was a good starting point. It has questions. You can add questions. They have short questionnaire, just  to start getting a feeling. And then deciding on how you're going to apply it. Can you apply it by putting it in MyChart? If someone's coming for a visit, they  complete the questions beforehand. Can they complete them in the waiting room? Can they complete them before you come in the room? Now, I don't know about your clinics,  but I'm always pressured that people are too long in the waiting room. And can you move people faster through the waiting room? They don't care how long they're in the clinic.  It's just they're in the waiting room too long. So why would I want to give them more questions to answer in the waiting room? Also, that choice may be taken away from me.  And also, getting providers and nurses and medical assistants and front office people to start thinking a little bit different about how we're asking questions  in terms of dealing with society or social factors. So here we are. We encourage exercise. We don't ask about the safety of the neighborhood. I live in Toledo. It's a great city.  But our economy has been turning for the last 20 years, right? So the gains we make. And I go walking every day with my wife. And during the daytime, I would walk.  In the evening, after dark, it sounds crazy for me to say this stuff. But I'm much more concerned about, not just because I'm concerned of something happening to us.  It's just that the sidewalks are not repaired. There's the trees are not whatever. There's too many factors at nighttime to make it walking in my neighborhood at night.  So if I get home late from work, then that's an issue. So do I get up early in the morning and do it? And this isn't just about me, guys. I'm just trying to give examples.  This is what's happening. So what about weight loss? Here's our number two. These are the number one, two things we talk to people about all the time. It's too simple.  But really, maybe we don't even know if they get secure food. Many of these neighborhoods, for example, in downtown Toledo, there is no supermarket.  There is no Publix or Hy-Vee or Kroger. The closest one is probably within four miles from the downtown area. So there might be little shops where you can buy food.  But it's not necessarily going to be healthy food. And part of the programs that they've done through ProMedica, and I'll review that,  is that they now put a small supermarket, more shop, not supermarket, right in the center of this food barren area. Then vital signs, we ask about vital signs.  We don't necessarily do mental health checks. Child growth, toxic substance stress, physical examination. We don't even ask about insurance  in terms of if they're going to need further testing, how is that going to be achieved? Or if not, where can they can do it? We provide education to patients.  We don't ask them if they can read. I mean, maybe we do. I mean, we do now, right? But when you're in the room clinically, unless I know that as part of the record,  it's not the number one question I'm asking, where it probably should be the number two question I'm asking if they can interpret this information.  And remember, because of health literacy, what I'm saying to them the first time, they're probably not clearly understanding or getting it all the first time.  So am I willing to go through everything a few times? The average is about three times for people to take information in. And then criticizing patients who've  failed to show up for appointments. We don't do that in our exam room, I hope. But it could be that staff are talking or whatever it gets out. And we don't have to even ask them  about transportation issues. And we'll see that transportation is a big determinant whether you can get out of your neighborhoods for anything in our society.  We don't have walking communities. We have communities that are based on the need for transportation. So in Promecca, they call it the social determinants of health wheel.  But what happens is they complete questions. And it gives us whether there's a risk factor for a particular, we call them all social determinants of health.  But see, here's tobacco use. Here's postpartum depression. Here's alcohol use. Again, are those social determinants of health or should they be in the individual category?  But we look at 14 of them. They identify if they're at a risk, medium risk. And these are where we can start directing attention. The good thing is we can go help with looking  for community resources. If you're a small clinic and you're using the American Academy of Family Practice model, you have to start collecting these community-based resources  to be handing out. And then the other thing is we can look at previous recommendations. Have they improved? Have we done an intervention or made a recommendation, made a referral?  And are we seeing some improvement? It's not reporting a percentage to us of the group. It's just to that person we can go back and look.  So I'm sorry, this is the thing with looking for questions was that some of the questions are hard to read, literally. But in this question, this first question  is asking about you and pay in terms of paying for general things in life, housing, medical. And then further down, when we start asking questions about food, we refer to we.  And that's an important concept if we're thinking about social determinants because if I have people that are dependent on me, I should be thought as a we, not me.  Do I have enough money to buy food? No, it's do my family or my network, my extended family, have the ability to do that? And so we have to start thinking in those terms  as well when we're thinking about that. And then here, again, have transport back to you. For you as an individual, can you get to work? Can you get to a medical appointment?  Can you go to the pharmacy? Again, about four or five miles away to get your medication. And then in terms of do you lack transportation? So those are what the questions look like.  In terms of a clinical setting, apart from all the other information we get in front of us, we get this window, which is now great. It's right in the middle.  We want people to start thinking about it. And it isn't where in the past where we quickly go through your family history, social history. it's right there in front of us now.  And then we can spend some time on that as well. And we actually promote that. So that's been a real benefit in terms of saying it's in front of you.  As providers in the clinic, I encourage them, initially we introduced him, we read through all the questions. But I do encourage them to go back and read these questions.  So if I get someone who says he's a moderate level or he has a high level, I encourage them to go back and see what questions were used.  So they can maybe get a little better understanding of what the risk is. Remember, it's not just outcome, it's risk. We're managing risk as part of our clinical interaction.  Let's get by that.  Okay, the other thing is coding. And that was an issue, and I guess since COVID, it's become less of an issue. But the fact is, you might have coding, but  you may not have any payment for that coding. And so, can we in clinic have a visit clinic for a social determinant of health, can we have that?  And if we can, then we have to have one of these categories, there's about ten of these guys. And it's worth reading through what each of them are doing, but  it's education, employment, risk factors. These are industrial occupational risk factors, housing, we'll go through the other ones. So, but it's how are you gonna get paid for  that visit if that code is not reimbursed? And so, now I have to attach it to another visit that potentially I'm getting paid  for, so in the future, would we want to have a visit for a social determinant of health? And this is occupational medicine, guys, forget about family practice,  they probably want to. But in occupational medicine, what we find is that a person's, an injured worker's ability to heal or willing to go back to work or  do rehab are intertwined with a whole bunch of psychosocial factors that become barriers for them. So we use HBAIs assessments in terms of health and  behavior assessments, determine if they're motivated to do some of this stuff. So in the future, we may want to be able to say,  that person had a transportation issue, they didn't get to physical therapy. That's overcome, I want to know that things are beneficial.  Or if I'm approving treatment, you didn't go to your prior physical therapy, why would I want to approve more physical therapy, you didn't use it?  And really, it wasn't that you didn't want to go, you couldn't get there. So you couldn't leave work, you didn't have flexible work hours,  you didn't have transportation to get there. So hopefully in the future, we'll see that these codes will come. In Ohio, I work with the Bureau of Workers Comp.  In our system, the Bureau is the insurer as well. And so these are really important topics. These will come down the pike for us, but in other states, it may not be so simple.  And here's the other ones, this is social environment, upbringing, primary support, psychosocial circumstances.  So those are the codes. So let's talk about work and employers and things that can be done. So work as it is itself is a social determinant of health. I'm sorry.  So itself is a social determinant of health and impacts the distribution of injuries, illness, health, and well-being in society.  So what happens in the workplace, it then goes into society.  And some of those connections, if you can't do your job, or you're injured because of your job, then maybe your income drops.  It means that maybe you can't cut the lawn, all these things. You can't do the shopping, you can't help pick the kids up from school.  So the impact is a ripple effect right back out into society. It interacts with other social determinants of health, employment stability, social and community context,  how our injury is impacting a long way from the workplace. Past beyond specific work conditions,  these are a lot of these socioeconomic type issues that are impacted by work-related injuries. So work can contribute to inequities as a social determinant of health, or  it can have a positive impact, increase the health, equality, and well-being. And that impact, if we look at work as a social determinant of health,  as we improve the workplace, as we improve wages,  as we improve benefits as factors of components of this social determinant of health, we can have a positive effect. Remember, they can have either positive or negative, and  our impact can unfortunately be positive or negative. We don't always know that until we get started.  In occupational medicine, we've worked on a framework of occupational, sorry, we worked on a framework of occupational health and safety. Its roots are in social medicine.  And the purpose of social medicine was to address socioeconomic conditions that impact health, disease, and the practice of medicine. And in public health and preventive medicine,  we probably dealt with that more. Part of the reason for being in occupational medicine is that we get to deal with groups of people, not just individual cases.  And so our impact in the workplace can impact quite a few people. Seeing a particular injury can tell us that there may be something else out there that can be impacted.  But over the last 50 years, occupational health and safety have become more of a technical field where we went out and  looked at chemicals and physical and ergonomic risk factors in the workplace. This is what we all grew up on. And it was this biomedical model. This is how we've all been trained.  So we're actually forcing ourselves to take, look at things differently.  And then it was, we also focused on a single factor. A lead exposure, a chromate exposure, those type of things in the workplace. And they worked out the exposure.  We worked out as a risk. We looked at how preventive steps we could take to reduce them. And we worked out surveillance of employees that are spending ten, 20, 30 years working it.  So we've learned to manage many workplace hazards. We've improved the worker health. The workforce itself is healthier than the general population.  And so when we put them all together, we're actually increasing the health of the general population. So keeping the workforce healthy is an important factor.  There's been a significant decline in work-related injuries and illness. Those bread and butter musculoskeletal disorders are not as frequent as they were before.  We have a lot of interventions that have reduced them. However, not all workers have the same injury risk, even when having the same job.  And that's where we should be thinking about social determinants of health, is that there's something else impacting them. And we think initially of things like fatigue, stress,  work shift changes, things like that, that we feel a little bit more comfortable with. And so we're gonna have to get further and further into the social determinants of health.  So with that, these are inequities associated with the determinant. We know that the reduction of instance and then rates of workplace injuries have gone down.  However, the rates are uneven across work groups, and that's what we're going to have to start figuring.  And these workplace inequities are avoidable. Inequities are avoidable and unfair, and they should be addressed. The tools that they've had in occupational health and  safety is epidemiology, screening, surveillance, and is participatory type methods. We've had interventions, we do interventions in the workplace frequently.  If you think about hearing conservation, we do often make interventions and change people's exposures, reassess exposures and risk. And so that's been very familiar to us.  So these tools, we know work in the workplace, can we make them work for social determinants of health? And there's been other factors that sort of that outside maybe  social occupational safety and health is the reorganization of work.  Externalization of risk factors, we have more subcontractors, we don't have to take the risk on, we're putting it with someone else. And we have the competitive bidding process,  the unions, and working with them to make sure that we get adequate coverage and we can build in factors influencing these barriers.  So this is the total worker health sort of diagram. And so with occupational safety and health, the paradigm is switched. We have influences from outside sources.  And so our biomedical model has changed. We're doing this biopsychological, sociopsychological model, the holistic view.  We sort of got into the holistic discussion with the health risk appraisal and these individual interventions. So again, it seems like we keep on pushing towards that direction.  And so we're looking at multiple factors. But really we're looking for these interactions, biological phenomena, social factors, and social relationships with those factors.  And they're all playing off of each other. It's supported by NIOSH to conduct and support health equity focused research, and this is the program.  So some of these factors are a little bit different than in terms of how they're titled, but it's all about worker well-being. We now talk about health and well-being.  We talk about what is well-being. So again, probably well-being and holistic are gonna be tied together. But we're adding well-being to a lot of our conversation,  not just health, but well-being. And health, remember, is a non-medical thing. It's a state of mind. Medical, healthcare centers are medical. Clinics are medical.  Diseases are medical. Health is not that. And so well-being is gonna be part of that.  So here's our five foundational social determinants of health. And why would employers even wanna look at? We have to get their buy-in, and the bus doesn't run by my house,  doesn't seem to fly when I try to get buy-in. But I do know, by improving some of these barriers, is that the employer is already dealing with these performance concerns,  attendance issues, stressful relationships, co-workers and managers, behaviors. These are high turnover rates. You guys know all this.  And what it does for the employer is better for business, and improves the health and well-being of their employees. And with that, they get improvement of these measures.  Here's a return on investment for an employer.  These don't even have to be dollars. These are just less turnover.  Better attendance.  If we have employees that their behaviors are changing and their attendance is changing for the worse, we probably immediately think there's a drug or alcohol problem.  We may not have any understanding that there are different barriers in play. And so that's the buy-in from the employer.  How I get a return on investment is that, let's look at it over a year, have we impacted, and we have lots of things we can look at. That they're already looking at themselves.  So we have the measures out there for employers.  So as solutions, because they do want solutions, and we want to help them get solutions. And a lot of these solutions you'll see in a later slide, it's small groups,  the stakeholders, the committees at these companies, committees and communities, making suggestions based on experience of that company.  So a lot of these interventions are very focused on specific communities,  specific groups, can we enlarge in that focus? Or can we better define that influence or intervention to have a positive effect? So here's healthcare, promoting preventive care.  A low wage worker doesn't have preventive care.  By doing that, we're preventing down the road downstream costs. Promoting employee having primary care physicians, that's a wake up call.  And then offering telehealth options, how can we do it? Not just for their injury, work-related injury and illness.  I think there's some talks this week about how we're gonna be doing that more and more, but also for that, when they come to the clinic and say,  can I see their person who has a cold who lives 50 miles away? Why can't they have this option themselves and apply that on the work site?  Socio-economic, promoting financial well-being, and then 78% of Americans live paycheck to paycheck. And I used to think it was in poor neighborhoods, but  the reality, I really find it's in a lot of neighborhoods that people are living. And probably living outside their means as well, but  that's a big percent of the American population that's living paycheck to paycheck.  And then there's educational things we can do. We love education, we love telling and talking to people about things. But the nice thing about social determinant health,  we can then connect you to the community. There's community resources. They're not only going to educate you, they're going to hold your hand or help you take the next step forward.  And then neighborhoods offering, talking about air and water quality, transportation subsidies, and flexible work schedule. Air, a very important part of people impacting,  an individual having an impact on social determinants of health. And then stress management, addressing well-being, but also for  the workforce in terms of worker relations, worker development, and worker workload. We look at workload all the time, and we believe different jobs have different  stressors, and if we can address those stressors, the outcome will be better. So hopefully, these are things that an employer can buy off on.  So I'd like to look at four studies. So let's start with the low-wage worker. We don't have to know any other demographics about them,  because we just want to go through a simple logic. So it's a low-wage worker. We'll say, okay, sorry, I got it wrong, socioeconomic factor about them. They make about 35,000.  Whatever you say is a low wage, that's the number I want you to use. They're spending a large portion in their communities of their income on rent, food, and transportation.  Those are the big three.  They find a lump on their neck. They twist their ankle. It's an unexpected health concern. If it's a twisted ankle and I'm hobbling around, I may do something sooner  than if I find a lump in my arm or my neck, or I have a little bump on my belly button.  Then I might not, it's a concern, but I'm not going to do something about it. And part of the reason for these type of concerns, they're worried about the cost of the doctor visit.  They're worried about lab tests, if you send me for a lab test. And then they're worried about deductibles. And that's where, on the other side, on the employer side,  the company health plans often have high deductibles. Either they don't have a health plan available to you, or the deductible's not manageable.  And so we end up with a lot of under-insured workers. So we may say they're the working poor. I think we used to have this sort of dialogue about the working poor.  But the reality is, at this point in time, this unexpected cost, they may be the working poor. Without that, they may just be working and getting by, able to pay all these things.  But this little bump in the road may become a big hurdle for them. So it turns out about 41%, they put off care. About 40% report dealing with unpaid predictable bills,  these are these deductibles, or other unrelated debt.  And so the impact for the employer, this says employees, I apologize, the employer, is the bottom line because their health care cost is going to go up  with their plans as they use more expensive care. And what we do is get a delay in the diagnosis. So there we have the low-wage worker. They've got an unexpected health concern.  So let's just take a quick look at the low-wage worker. They're less likely to have a primary care physician, we said that earlier.  And they're more likely to obtain their care in the emergency department. Actually, if you don't have a primary care physician, and  you have any spectrum of health literacy being illiterate, you probably don't even think about urgent cares or walk-in clinics,  which have filled a big gap in the health care system. So it is either our primary care doc or the emergency room.  And when I've been putting it off all day, it's the emergency room. And I think about it at 2 o'clock in the morning.  But that's where they're seeking care, and not through their primary care provider. And that's due to awareness of low-cost alternatives, urgent care clinic,  reasonable access to transportation. So they have to take a bus or so many buses to get there, and inflexible work schedules, and where they cannot get out.  If my primary care provider, I want them, but they close at 5 o'clock, I have to be able to get there for my 4 o'clock appointment.  And can my work schedule, without taking a day off work, can be flexed that way. And now when we do telecommunication, teleworking,  that may be a possibility where I start the day at the clinic. And I don't go to work, I finish the rest of the day at home,  working from home, and that may be solutions that we need to be thinking about. The resulting is it's a poor health outcome based on their health concern.  There's an increase in preventable diseases because they don't seek preventive care. Late stage diagnosis and treatment of chronic diseases, and that's ongoing increased cost.  And increase in use of higher cost treatment sites like the emergency room. And that is a measure we use in health care to see is reducing the use of the emergency room.  The visit to emergency room for a pregnancy test, how do we get around those sort of situations?  So let's go back to our diagram. So what can be done in this situation? And a lot of this now becomes an employer type thing. They can promote healthy behaviors,  implement flexible work schedules, offer transportation assistance. And then what can we do in the community? What can an employer do in the community  is they can connect employees to people and resources. They can promote healthy habits. They can start regular exercise programs or access to health care systems.  And clinics that maybe have low cost clinics or no cost clinics in the community. But if you haven't had a health problem, you may not know about that they exist.  That's a resource that's around the block from you. You may not know it's there because you haven't been accessing health care on a regular basis.  That's the, so what we've done is we've brought local employers and community projects together for a better outcome to overcome the barriers for good projects.  This is probably classic public health, but these are interventions in our communities, in our communities around our hospitals and in the workplaces that we deal with  and that we can take these steps.  The other problem is COVID and during the pandemic,  based on the industries, low wage workers lost the largest amount of jobs. And so what that does is remember, rent, food and transportation were the top three things  where they're spending their money. If I don't have the money for rent and food, forget about transportation, where I need that transportation to go get the job,  those two become big issues. And so food and housing are really important. And housing are really big issues in terms of insecurities in stressful situations, not just pandemics.  And there was less loss, but they were above the industrial average, which was 6%.  So they oftentimes in terms of looking at interventions, we talk about a need, we talk about intervention, we talk about some sort of measurement  where we reassess, readjust the program.  So what we start out as a need may change and when we impact it, we do the new measure, then the need may be different and we have to keep on recycling through the process.  So I'm gonna tell you about three industries grouped together. They are companies that were doing good growth, good wages. And in terms of surveying,  doing applying social determined health questionnaires, they found that 51% of their employees were struggling housing and heating expenses, 41% with food insecurity.  And this is great, 29% feeling that they have a little or no purpose,  little or no purpose, almost 30% of our workforce. And so that itself is a big issue.  Health, it will see is here the company identified that behavioral health was their main priority. They were going to look at financial strain, food strain and lack of purpose,  but they were concerned of what little or no purpose meant in terms of that person, which was great. And then the impact on the workplace itself.  So this is a food intervention clinic.  This is what we use at ProMedica.  And this is with people who screen positively, positive for food insecurity, their referrals. It's almost like we were writing a prescription for food.  It's a two or three day food supply per visit. They get one visit for up to six months.  We also offer nutrition counseling, healthy recipes, and most importantly, I would say connection with other community services. Any of these food type services,  the little stores that we have, we find that it's an indicator of mental health issues in our stress issues in our society. And so for the staff who are working these sites  or these types of setups, their ability to have other resources available to them, they become the new evaluator of the social determinant barrier and to make those resources.  The purpose is to reduce food insecurity, increase access to nutritious food, provide counseling. Food is a medicine, but here they partner  with local food banks for healthy food options and also as other community resources. So when we looked at 2017 and 2021,  there's over a thousand participants in each group that were identified, mostly female,  greater than 40 years old, 43, and went down, it went up afterwards in 2021 to 57,  and mainly African American, a large proportion.  But what's interesting is they had a number of health conditions, greater than four health conditions, 48 and 39%. So they're already an ill population  that are managing a stressful situation of food insecurity.  And then these were the top four in 2017, hypertension, depression, asthma, then obesity. That changed in 2021 to anxiety. And if we look at what COVID in terms of reporting  of social isolation, anxiety, depression, suicide, substance abuse, opioid overdose doses, those have all gone up. So we're probably not too surprised to see anxiety hit the charts.  And then here's one of our measures, readmission rates. This is the food clinic FC. It was down 5% when we compared to the same  in this group of people that didn't use the food clinics, which actually their admission rates are up 8%.  The average number of visits per household was six,  and they participate with, and of those six, 50% used over three of them, which was great. And here's sort of the measures, health literacy challenges, 54%.  And then food strain, food insecurity. And then here's this transportation barrier. And this is one of these questions I wanna ask you about  is when is the percentage low enough to say  that it's not an issue anymore? Because these measures are always gonna measure a percentage. And so if I think about just transportation,  I think about two things that may be barriers. One may be there's no public transportation, right?  So it's communities that need public transportation.  It's not readily available. But also it may be that that's where they're having to put their resources to go to work, gas prices go up. That means I have less resources for food.  I have less resources. They're still working, but transportation at 19 seems low compared to the rest of them. And if I were directing my attention as they did,  they've directed to food, transportation may not be looked at for a while, but it may be part of the source. And this is where the social determinants interact with each other.  If I impacted transportation, could food fall out of the place because now they have more food. So as a priority, I'm giving my car more meaning  than I'm giving my refrigerator, that type of thing.  So here's some things that employers that through discussions have talked about. So, and why some of these things really obvious and they probably should be done.  It isn't that simple to do that because not everyone wants nutritious food items as a choice at the onsite cafe, right? You think they would, but that's not how it happens.  But to purposely offer those, to reduce costs for healthy food choices. So it's less expensive to eat healthier. And the employer has some control over that. They can negotiate that  with the catering services providing that. And then this idea of bringing product markets to at lunch hour to the workplace or bringing take home meal services  at the end of the shift so that they're taking home healthier food. Especially if you live in a food desert where on your ride home, you may not be stopping.  And if you do stop, it's maybe a fast food or not a food source is not healthy. And then so, but that's a general thing in terms between large and small employers.  This is a grocery discount card where you got a $50 savings on a card weekly but it was for healthy food choices. If you did not make the healthy food choice,  then you couldn't tap into this benefit.  And that was organized with a local grocery. And the other is to coordinate with a local cafe to provide healthier lunch for employees once a week.  Something to get the community involved. Now, employees are spending dollars in their businesses. So it seems like a possible solution. So let's look at finance.  This is the same company here. Financial strain was above food in terms of where the intervention should go.  And in this program, what they do is it's integrated health services finances. It's actually in our program in Toledo. It's in the same building.  So if you come shopping and I hear something of a concern then I can send you here. I can send you here directly from my clinic or the clinic I work for.  And the coaches are certified in terms of credit counselors  and tax information in terms of services. What they're really looking for is long-term engagement. And they want people to come at least two to five times  for assistance, two to five times. And finances is an engagement problem because if we look at that low wage worker who had the health concern and they didn't have money for care,  this would be a very good interaction. They may not need this on a regular day or perceive they need it, but it may have it available.  And so they do your credit rating and your balance sheets. They help you start thinking about where your expenses are going. They help you look at budgetary items.  And also they look at your career path for that if you need any legal assistance. But also the program has this where if you make a deposit of $25.99 monthly, they see it as a loan.  If you're making a loan payment, they report it to the credit units that helps your credit rating. And at the end of the year, you're paying off the loan.  They give you the other part of the loan. They match it at the same, around $600. So a way to impact your credit rating.  And each coach, we expect to touch  200 participants or more a year. But we really want this sort of long-term interaction to come into play. And so looking back in 2017, 80% were female. 52% were 18 to 40.  And then African-American over 50%. And again, here a higher percentage had chronic diseases. It reduced a little bit. And here the same chronic diseases.  So when I was looking at this with somebody, they said, oh, here's our group. We've impacted this group.  Part of what we're trying to do is not talk about groups. We're trying to talk about barriers in our community. And so the question was,  what is the next group of people we can impact? Really is, what are the barriers in our community that will help them use financial services or direct them to do it?  So I don't wanna say that this group is female that are over the age of 40 and African-American with more than four conditions.  That doesn't help me affect a barrier in my community. Those are outcomes. We're trying to deal with risk. So just using these sort of numbers help us as measures  to say success or not, but they don't necessarily point about which barriers need to be impacted next.  And so in this program, which is great, their incomes went up in both years. Their credit ratings went up in both years. Maybe COVID helped our credit rating go up,  but they went up. ER visits, the cost went down, reduced cost of 2,000 or 9,000. And then here's, remember there are two to five visits. They're actually averaged about eight visits  with over 50% already having completed three visits at this point in time.  And then in terms of these, in this group going to use a financial service with social determinants of health, they had 45 health literacy.  This was 54 for financial strain in the food group, 31 and 41 in the food group. And food insecurity was 34 here. So this sort of reflects what we would expect  between which group used which services. But in the food group, it was 19% for transportation and 6% for the financial situation. So again, is this a low enough number  not to be worried about transportation as a barrier in that community or in this group of people? I don't know the answer to that, but they do interact with each other quite a bit.  So, okay, so here's financial counseling offered at discount rate or onsite. These guys had a 30 minute free one offering wellbeing benefits for low income employees.  And one of these things is sort of accessing wages before payday where they're not living paycheck to paycheck, they're living until their money runs out.  If that's a few days before payday, how can we help do that? And having a payday rainy day fund.  So not being mad that someone's asking for their check early regularly, if other indicators are good,  and it's not what you're seeing as a target, as a risk factor, such as absenteeism, behavior changes, aberrant behavior changes in the workplace  that they're living money to money, not paycheck to paycheck. So having some flexibility with that. And then other things, just say examples are transportation vouchers for travel,  flexible work hours,  attendance and tardiness policy. I think it's leftover from school and we have to get a better way to manage. If society's impacting us,  these should be a little bit different policies. Flexibility remote work, and we've learned quite a bit during COVID. And the other thing was discount car repair.  People having mechanical problems not being able to repair their cars. Then housing, again, workshops on home buying, legal assistance, caregiving, flexible work hours,  reserving places at the daycare centers for employees with children, and then backup care.  Those type of things are a real value. And these are practical things that people, companies or communities have looked at.  I'm just going to quickly go through two more. The HERO Program is a nonprofit national program established about 20 years ago, identifies and shares best practices  in the field of workplace health and wellbeing. In terms of social determinants of health, it focuses on employer business implications, implementations of the factors themselves.  I just want to point out a few of them. So just as background, we talked about zip code. Your zip code could reflect how healthy you are or what your real barriers are.  We don't even have all the, the understanding of all the social determinants of health barriers are in that zip code.  But things they can do is address injuries regarding increased work demand, autonomy. These are things in the workplace that have a benefit at home.  And then in terms of financial stability, poverty, remember we have a working poor, we have an under insured population of a low wage. They're already having health risks.  They're increased risk of morbidity, mortality. Their life expectancy is about five years less. They have poverty impacts your quality of life,  higher rates of smoking, those type of things. 29% of Americans did without medical care due to financial issues during this period.  And so, and then things like insurance, pathways to promotion, those type of things. I'm sorry, I want to give you some time. I'm gonna have these, these are the other ones.  So I just want to just go over the last one. ProMedica is, they have a national institute. I'm not part of that, just so you know. I use, look at their information a lot,  but I'm not producing information for them.  And they, their mission is to create healthier workplaces by redefining health, investing in communities and leading the charge. And we have this neighborhood program.  It's, it addresses social determinants and supports long-term community health and growth. And it's in the downtown Toledo area.  Again, there's a lot of barrenness in terms of resources. So the number of barriers are numerous and high. And they have actually been working on programs  in terms of education, using local community businesses to provide services when needed. They provide scholarships within that community level.  But also, they purposely worked to educate the providers in ProMedica through the care division with the understanding and how to use the social determinants of health.  I'm going to skip this, guys. This is just background. We've got a few minutes. I just want to leave with this. This is my view in terms of how I'm  trying to work to understand social determinants of health. So here they apply. It can be in a community, in a neighborhood. Here's where policies are made.  And with that, social determinants of health, when I want to go to government, because there could be too many on the list or too difficult to manage,  to prioritize, they don't get active. There's a barrier there for that. With government policies, I know about biases and privileges. And so what happens, they can impact  these social determinants of health. This is the upstream effect. Once I'm in the midstream, community services are all impacting here.  But I still have the social determinants of health. And this is where inequities and disparities come into play. This is when I come out of my community,  my risk for health outcomes and different outcomes can vary because of the disparities and inequities in social determinants of health. When I deal with the health care system,  we're also dealing with workforce diversity and what is health equity. And that, if I work for a system, I have to plug that in.  If I'm in an old clinic setting, I'm not so influenced by that. I'm influenced by what the look of those risk factors are and those outcomes and individuals coming  from the same community. So that is my thing. I just added this to the quote from last week. Health begins in home and at our doorstep and not in the clinic.  So our communities are impacting us. And that's my view. And hopefully, that's useful information on social determinants of health in the workplace. Is there any questions?  Can you use the microphone? I'll just repeat them. Yeah, really great talk. Really enjoyed it a lot. I was wondering, I saw my health care organization just  got Epic last year, so it's all very relevant. But I was wondering if you've spent any time with the IT staff, either on your local level or nationally at Epic,  to try to ease that transition to get patients to where they need to go once they have identified. And related to that, have you identified any grant funding  to fund that programming cost? Yeah, on the grant question, I can't answer you because I'm really not in that committee. But in terms of using them, the IT  has just allowed us to get that front and center, get us to define what social determinants and the measures behind them. And we are uploading resources in our own communities  because of the National Institute for Social Determinants Health at Prometica. They're helping us put that together. So there are known resources and categorizing  how we can resource it. But it's not an easy algorithm to get through. It is a challenge. And before, the screen wasn't right there front and center,  so you didn't necessarily have to look at it, right? You should, but you didn't necessarily have to do it. Yeah, it is a challenge. It's a great program, really a powerful tool.  But it's a challenge for the future planning of the outcome.  I apologize. I got here because I didn't hear. I called your name, and I sort of checked you off. My ears were burning. You do really good work. This is great.  And it totally checks the boxes of total worker health. I'm just curious, because I have a lot of employers that I can't really book to care about the wellness aspect.  What's the sell for you? How do you go about booking the employers? Yeah, so on one of the slides I have where I list the social determinants of health,  and let me just get to it, and I'll just read you what they are. But for the employer, in any of these discussions, I often talk about tardiness, behavioral changes.  Let me just get to it. So performances, attendance, stressful relationship between workers, high turnover rates, low employee engagement, impact on workers' ability to work.  Those are things there with total worker, right? That's what we're trying to impact. That was the low-lying fruit. So that's what I hook them with, is  can we look at these determinants, measure them, and if there's a movement in them in a positive way, has that been beneficial? And tardiness, attendance issues,  could be transportation. And it doesn't necessarily have to be that I'm always sleep late. It's just that the bus was late.  I looked at it in one company that winter weather, snowing, when you have bad parts of the winter weather when it's snowing, can we be flexible with attendance?  And it's not that school starts not at 8 but 10, late school starting. A lot of employers have that. But because if the weather is going  to go longer throughout the day, how many people can we have at home and not have to come in and still get the work done?  So lots of times, there's specific examples in front of them. And that example only came up because of COVID, is that we have a committee that dealt with COVID issues of attendance.  And it just sort of dropped in my lap because it was in Ohio, where it was snowing, right? So were they out because of COVID? Or are they out now because of winter weather?  And how can we still manage that going forward after COVID has passed? Thank you. This is one follow-up. Are you dealing with the safety from employers or HR  to implement drugs or benefits or all? Yeah. The benefits or human resource part is the second. I always deal with safety first with those interventions.  They tend to be more willing to address it if they have to address it right away. And then making the argument for the human resource part of it. Go ahead.  I'm working with my employer to kind of devise a more robust health strategy. But they want numbers. I'm struggling to find data. They want to know the return on investment  before they do anything. So I've been trying to find literature, trying to find information. Because they do, yes. They agree. It's great. They want that. Yeah.  So not to promote where I work, but they have an institute. I don't work for them. But you could contact them. But Robert Wood Johnson has a big effort to do this.  And because we talk about social determinants of health, we don't talk about total healthy worker. So they have a lot of these impact studies. And these are small programs.  They're focus type programs or interventions. So those would be really two good sources for you. And they often have ROI on this. It's funny. We're talking about ROI.  But all wellness is always done with that. It's always been a difficult issue. Some large companies, in terms of having wellness programs, some of the beer brewing companies  have ROIs on this stuff as well. So it seems like many of the interventions that you mentioned address the social determinants of health. For example, for people with a paycheck  or money to money, or shorter-term solutions, if an employer is providing some type of relief fund, eventually the relief fund is going to run out,  or it's probably going to have a limited term, or else you might as well just increase the employee's pay, which seems to be part of the underlying issue.  They're not getting enough pay to meet their living expenses, at least the way that they do it. So it seems like that what you're looking for for a wellness program  is really maybe young resources, or are there things that you can do, like educating persons to manage their expenses, or to optimize their expenses, if they're not doing so well?  Right. So a lot of this is prevention. Can we get to you before you overspend? And you're right. If you have a rainy day fund, that could run out.  And so that's part of the reason having the committee of the management, some of the stakeholders, and employees as well, so that they're all saying,  how do we keep everyone informed of where we're at? Companies put up lost days, lost injuries, to remind employees, because sometimes they're tied to benefits.  Sometimes they're tied to other measures, to remind them, if you're having an injury, report it. We don't want you going off work and coming back later.  And if you can avoid an injury by practicing good safety, we want you to do that. But you're right. So it could be that the argument to an employer is, here, you're spending this.  Would it be easier just to give someone a raise? Or if we give someone a raise, do we need this benefit? And that, I guess, would be the challenge, which comes first,  in terms of, do we give the raise and say, we're not going to have this benefit any longer? Transportation is a problem. You're not going to solve that.  I mean, maybe if you have a cluster of employees in the city area, your transportation is going to be fine. But if it's in a van, you're going to have to pay for transportation.  Right. And that's why the social determinants, they're not going to go away. It's just whether they're positive or negative.  Building issues are not going to go away. They're going to be positive and negative. And can we move them to positive? And like I said with the transportation, transportation is 6%.  Is that really a positive, in terms of where we need to focus our resources now?  Yeah, the intervention is community. Remember, upstream is government. Them saying the policy that the bus is going to go on this road, or the transportation system  is going to go that way. I mean, that's a bigger lift, right? But these community projects can be impacted. And the employer can have a role, both as an employer as a stakeholder,  but also as a source of the social determinant of health. Any other questions? I think that's the point that I get when I'm coming back to the presentation,  is that I think, as clinicians, some of the major upstream problems that we've dealt with, I think, at the earliest, acknowledging that we're at least a huge portion  of the rolling workforce. And the employer's interests are adversarial to the employee's interests. And I think that, in this case, it's going to be a refund.  Simple arithmetic, in terms of you're not having enough money to pay your employee, et cetera, et cetera, that kind of thing. Our wages, and that's where you're  going to come up against a hard limit for these employers. And I think that's acknowledging that you're dealing with adversarial interests. Not everybody's on the same page here,  and at the same end of the health insurance. I mean, no matter what you do in terms of wellness, that huge percentage of low-wage workers  that have no clients at all, or pushed into medicine, we have to, I think, as clinicians, sort of acknowledge that we're talking about the key interests here.  So when you're talking about huge, huge causes of this, huge percentage of causation in any one of these health outcomes, at the very least, acknowledge that.  Don't have to be explicitly saying that this is what we're dealing with. Right, that's right. And also, when you're in a clinic dealing with it,  you have no one to acknowledge it to. Sitting on these committees, it's almost like the preamble to say, this determinant's not going away. What are we going to do with it?  And just like I told you, having healthy food at your on-site cafe, you should think, that's an obvious thing. But there is conflict of interest. So it's sort of like this.  If I gave everyone the same bike, some people would perform better than others. If I gave you a choice of bike, I'll get everyone to perform a little bit better.  You will perform better. The whole group would be. So that's where I think is, with transportation, if we can unpack that some people are now in the group,  are getting over the barrier, they may be part of how we get other people over the barrier. And because those barriers are going to be there. And so if I'm giving you the same bike,  we're not going to get the same work done, the same distance. If I give everyone the choice, they're going to make choices that hopefully are going to move us  in the right direction. OK? OK, guys. Thanks a lot. I really appreciate your time. Thank you. Thank you.  Oh, good. Oh, good, good. I teach MDH, Medical College of Wisconsin. Oh, do you? Yeah. To what extent can we use your material? They should be online. If not, just email me.  I'll give them to you. The PowerPoint? Yeah. Oh, OK. Yeah, please.  I did one or two where, for a college group, I called in for about 15 minutes. They had questions. So they did whatever their course was. And it was only this focus. So, yeah.  So any of that type of stuff. It's such a great, great subject. I think you did a great job. Oh, good. I think they have gone completely and totally  wrong, to a point where I think they're done by now. I don't know anymore. Oh, yeah. Which was either seven or six. Bastard.  I'm controlled by Mike. Can I see a picture of you? Yeah, sure. What's your name tag? Oh, there you go. There we go.  They should be online. If not, just email me. I'll send it to you. OK. Is your email in there somewhere? Yeah, it's on the thank you. I forgot to put that one up. Great.  Thanks a lot. Can I call you Kevin? Yeah, Kevin Smith. Wonderful. Thanks very much. Yeah. I travel back and forth between Toledo and Naples.  Thanks a lot.  Let me see if I can put the last slide. Oh, here's the last slide.  Oh, yeah, yeah.  The different thing. Yeah.  I know. Yeah, we come on a train just, you know, we provide medicine, but we're doing clinic. Here, if you just take a picture of that thing. OK.  And if it does, they're meant to be online. So could you briefly share some details regarding the? I was a lieutenant in the reserve for the medical corps.  Yeah, anything I can do for you would be great. Thanks.  Do I get these questions? Will they send the questions to me for this? It sounds like the internet sphere is going to explode. Yeah, it was off. OK, great.  Thanks a lot for your help. OK.  So probably, probably not, I guess. Because I thought, you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, I was going to say,  you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, I was going to say,  you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, I was going to say, you know, Probably not, I guess. Because I thought.  I can just speak at the podium. I don't roam too wide. But Dr. Yarbrough.  OK, I'm getting you set up. And then I have to go check on one more room. And then I'm coming and I'm going to join the session. But I just have. Yeah, no problem. Got a little.  So I guess they didn't have our presentation.  When it was uploaded. Yeah, I brought a flash drive as backup. And so it's already locked and loaded right there. OK, but is that. I don't know if that's going to affect anything.  With the virtual. Did they come in and say anything? There was a gentleman here. I'm going to double. Just a minute ago. I'm going to double check. OK.  We're starting in five minutes. OK. Yeah. What do you want to say, Dr. Yarbrough? So. I'll just pull a chair. So if any. So if any questions come in from virtual participants.  They're just going to show up in here. Just like if you attended last year. Like you'll see a chat and questions. You don't have to do anything else.  It's just monitoring for questions. OK. And those will come up just in the little window here. Right over here. Yeah. OK. I'm going to go double check that it's OK with that.  And then I have one other room to check in. And then I will come and attend the session as soon as I'm all good to go. Run, run. Yes. I don't think it really matters.

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