Ep. 126: Exploring Social Determinants of Health

Timestamps

01:33 – Stefanie’s Career Journey
03:15 – What Are Social Determinants of Health?
06:00 – Protective Factors, Social Risks, and Social Needs
09:48 – Why SDOH Matters for SLPs
13:28 – Real-Life Examples of SDOH in Practice
17:07 – Practical Interventions for SLPs
22:53 – Cultural Considerations
26:29 – Advice for SLPs
28:27 – Closing Thoughts and Upcoming Events

Resources Mentioned:

• What are SDOH? – ASHA’s SDOH webpage: https://www.asha.org/
• SDOH: What's My Role? – The SLP’s role in
• SDOH https://www.asha.org/practice/sdoh-wh... 
• SDOH: Tools and Support: https://www.asha.org/practice/sdoh-to...

Highlighted Leader Articles:

• SDOH and Pediatric SLPs: https://leader.pubs.asha.org/do/10.10...
• SDOH and Feeding SLPs: https://leader.pubs.asha.org/do/10.10...
• SDOH and Dysphagia SLPs: https://leader.pubs.asha.org/do/10.10...
• Interprofessional Practice in the NICU
• Podcast: Social Determinants and Pediatric Feeding: https://leader.pubs.asha.org/do/10.10...

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About Stefanie

Stefanie LaManna is a speech-language pathologist and certified neonatal therapist with experience working in various pediatric medical settings over the past decade. She currently works as Associate Director, Health Care Services at the American Speech-Language Hearing Association. In her role, Stefanie serves as the team lead on all priorities related to pediatric feeding disorders and pediatric health care settings. Her clinical interests and expertise include neonatal and infant airway disorders and using FEES with the pediatric population.

About Michelle

Michelle Gage, MA CCC-SLP, embarked on her journey in speech-language pathology during her undergraduate studies at the University of Mississippi, where she also worked at North Mississippi Regional Center, gaining invaluable experience in various therapy approaches. Following her Master's Degree in Speech-Language Pathology from the University of Central Florida, she has dedicated 25 years to empowering children and families in improving language skills and overall development. Currently residing in Mississippi, Michelle extends her expertise through telehealth services. Additionally, she proudly serves as the host of the SLP Full Disclosure podcast.

Outside of her professional commitments, Michelle is the proud mother of Mia, an accomplished middle school math teacher and all-around amazing human. In her leisure time, she indulges in her love for travel and cherishes moments spent with family and friends.

Transcript

Speaker 1 (00:00.13)

Hey, y'all, it's Michelle with SLP Full Disclosure. Welcome to the podcast today. We have an amazing guest with us today, Ms. Stephanie LaManna. She is the Associate Director of Healthcare Services in Speech-Language Pathology with ASHA. So, Stephanie, thank you so much for joining us today. I'm excited to have you here.

Thanks, Michelle. I'm so excited to be here.

And we are going to be talking about social determinants of health, something that Stephanie said that she loves talking about. And we're going to be talking about it and how it affects us as SLPs and treating our patients no matter what healthcare setting we're in, whether in a school, home health, hospitals, and how we can go about addressing these issues to provide equity in healthcare services, developing appropriate treatment plans as we move forward with our families and patients.

So that's what we're gonna be talking about today. So let me tell you guys a little bit about Stephanie. Stephanie is an SLP with experience in pediatric acute care, NICU, inpatient rehab, and community settings. At ASHA, she focuses on supporting SLPs working in pediatric healthcare and feeding disorders. She's devoted to neonatal airway disorders and family-centered care. Wow.

Lots of specialized trainings, things that as a speech pathologist in the school system, I know nothing about. So I would love to pick your brain sometime, but we're not talking about that today, but that is very interesting to me. So Stephanie, tell us a little bit about your career, where you've been as an SLP and how you ended up at ASHA.

Speaker 2 (01:33.504)

Sure, yeah. I always kind of, when I talk to people about my story and where I've been, I always start with, always knew I wanted to work in the NICU. Like, no one really knows that they want to work in a specialty area like that. I mean, some people do, but it's really common for people to go into undergrad or graduate school and not have any idea of what they wanted to do. But I was like, nope, I'm going to work in the NICU. Wow. So I really kind of focused on that path. I...

graduated grad school and went into my clinical fellowship, I started kind of backwards working in pediatric outpatient with babies and toddlers and children with feeding issues as well as speech and language. So I kind of got this really nice wide range of experience and then just kind of moved on from there. Went to Peds and patient rehab and saw a little bit of everything. And then I worked in the NICU for probably like six or seven years at a community hospital where

I live and I loved it and it was fantastic. And I learned so much while I was there and then I came across an opportunity to come and work for the ASHA team and I just kind of never looked back and I'm really happy about the work that I'm doing here.

That is amazing. The medical setting always intimidated me for some reason. think it's just something, I think those little bitty sick babies would scare me. So I'm so glad that we've got speech pathologists like you out there. So we're gonna be talking about social determinants of health. I think it's something that we all know about and we know exist, but that term social determinants of health is not something that's widely spoken about. We rarely hear that term, although,

We talk about those things, we don't talk about them in those terms. Would you agree with that?

Speaker 2 (03:15.906)

Yeah, for sure. mean, when we talk about what they are and what that word means, everyone's like, I know exactly what you're talking about. it's kind of like the terminology that's new to people.

So tell our listeners, define social determinants of health for us in your terms.

Sure, yeah. So I'll start with sort of like the technical definition of it because it is important to know and this social determinants of health sort of movement, I guess you could call it right now, is being pioneered by Healthy People 2030, which is part of the Department of Health and Human Services and the Office of Disease Prevention and Health Promotion through the United States government. So they define SDOH as the conditions in the environment where people are born.

where they live, where they learn, work, play, worship, and age. And those conditions and those environments affect a wide range of health, functioning, and quality of life outcomes and risks. So basically, like to boil that down into something a little bit more plain language, it's kind of where you do everything in your life and the conditions within those environments and how that affects your health and then your health outcomes.

Right. And how are, is there a lot, I'm sure that there's lots of research being done, like the research people that do the research. Oh yeah. So what is the research showing right now and how those social determinants impact your ability to access healthcare?

Speaker 2 (04:44.236)

Yeah, that's a really specific question, I think, in terms of just one social determinant of health. But it's important to know that there's five of them. And there's, for those who don't know, there's the neighborhood and built environment, so where you live and what your community looks like. There's the health care access and quality. There's economic stability, education access and quality, and then your social and community context or your people, your village, right? Mm-hmm.

and research is developing around all those different social determinants of health. But really what we're sort of finding is that social determinants of health are neutral. They are not inherently positive or negative, but it's sort of what happens within the context of your life that then affects your ability to access certain things or to...

to have positive or negative health outcomes. So if you don't mind for a second, I'd be happy to sort of talk about what those terms.

That was my next question. So yes, talk about what those terms mean,

sure. And I'd be happy to share after this, have a bunch of resources related to STOH on our ASHA website, so anyone listening to this doesn't have to memorize all this information.

Speaker 1 (06:00.174)

And we'll make sure to have all of that linked in the podcast. So that would be fantastic.

Perfect. So, SDOH really refers to the variables that are shaped by policies, infrastructure, and culture. So, you and I might share SDOH. We might live in the same neighborhood and built environment, for example, or we might go to the same school, or maybe we're a part of that same village of people. Right. And then there's also a couple different parts of SDOH, which include protective factors, social risk factors, and then social needs.

So really what those are, are what really should matter to the SLP when we're thinking about our patients. So those three terms refer to how STOH relate to clients on that individual level. protective factors are sort of like those circumstances that benefit a person's wellbeing and their health outcomes. So think about having access to like really abundant nutritious food.

You live in an environment that has clean air. You have family that lives near you, friends that live nearby. You have a strong support system, right? Those things all can help you have better health outcomes because you have a support network. You're living in a healthy place. Meanwhile, the opposite of that is social risk factors. So they're the circumstances that are associated with poorer health outcomes. So think things like housing insecurity, not having access to transportation.

social isolation. So if you don't have a place to live, you don't have a way to get to appointments, you don't have a support network, you're more likely to have poorer health outcomes, right? That sort of makes sense to us. And then the last part is social needs. So they arise due to gaps in access to goods and services. So a good example of that would be

Speaker 2 (07:53.674)

like if a baby requires like a specialized bottle or nipple system after being discharged from the hospital, but it isn't sold in any of the stores near their house. So that is kind of that need that then arises, which gives us a good opportunity to intervene.

Right. Why is it so important for speech pathologists to consider all of these social determinants when creating treatment plans and outcomes and that sort of thing?

Yeah, that's a great question. And I thought about this for a while before our conversation. And what I really kind of boiled it down to is there's a great quote on our SDOH resources on our website that says, social determinants of health help contextualize the relationships between health inequities, health disparities, and health care disparities your clients face. And I really love that. And the way we can kind of plain language that up a little bit is that everyone has SDOH, right? You have it.

I have SDOH. You know, an example I give a lot, because I'm not afraid to talk about my own SDOH in front of people, is that my husband and I live far away from family, and our closest friends are over an hour away from us. So if something happened to us, we don't have a strong support system in our direct area, because all the closest people to us live far away. And that potentially, while we do have a strong support system of people who are willing to drop everything and come in,

be here for us if we need it, that protective factor can then shift into a social risk if something devastating were to happen to us or if we just needed support. A good example of that is like childcare, right? Like we don't have anyone to help us with childcare. So I kind of think about it as if the SLP doesn't ask about SDOH, the downstream effect of that might be like if they're in an outpatient setting, they might...

Speaker 2 (09:48.908)

like dismiss a patient from their caseload who has missed so many visits or like no showed so many visits, right? And sometimes we like hear the word like thrown around by like administrators of outpatient settings, like the word non-compliant, like the patient's non-compliant, they're not showing up for visits, things like that. But if the SLP doesn't screen for STOH, they might not know that the real reason why the patient isn't showing up for visits is that they don't have a car, right?

And maybe the city they live in recently cut funding for public transportation. And now the bus routes have changed.

They don't have money for public transportation.

Yeah, they can't afford it. Or it takes them two hours, you know, just to take the bus or the train to get to that appointment. And that's not true for everyone, right? Like, but at the same time, screening for it sort of opens those conversations about how can we intervene to help our patients get what they need.

Right. Is there a specific screening? Like, is there a social, an SDOH screener, specific screener that SLPs in medical settings can do? Because I'm thinking about my role as a speech pathologist in the school system. And the kids come to school to access the services that I'm providing. And that's something that I never really think about too much outside of that education setting. So what screener do you recommend? Is there one that's specific?

Speaker 2 (11:16.386)

There are some specific screeners on the SDOH resources on our website. We have a specific tab for like tools and support that include a bunch of different screening options just depending on what your clients like what your caseloads needs are, what type of setting you're in, things like that. So there's a bunch of different options for SLPs to pick and choose from, you know, what might fit their needs.

Right. And I'm thinking about when I was working in early intervention, when I was in Maryland on contract with AMM when I first started going into people's homes. And then when COVID hit, went virtual, right? And I had never worked virtually. And I thought to myself, I wonder how this is going to work. know, early intervention is parent training, family coaching. It's not that, you know, direct one-on-one therapy. So how is this going to work? Is this going to work? What's it going to look like?

And do you know what I found? That I had almost 100 % attendance when we went virtual. Families that in the past had been, like you said, non-compliant, no-show, canceled at the last minute. And it was very interesting to me. And I've thought a lot about it since we decided that we were going to do this podcast. And I was trying to think of situations where those social determinants had impacted the therapy that I was providing in the different settings.

And definitely, and I think it's because maybe the house wasn't clean. Maybe they didn't have, know, and even with the kids that were sick, you know, they had a sniffle or they had a runny nose so they would cancel, cancel because they didn't want me coming in and getting it and then taking it to other kids. And same with me, if I had a stuffy nose or a little scratchy throat, I wouldn't want to go into their homes. But those are the kinds of things. And then thinking back to many, many years ago, when I first started in my career in early intervention in Alabama,

and just the physical therapy. remember being in really, really small homes and go, you know, once the team would go out and do the evaluation for kids that had multiple needs and the PT would say, they don't have room for a walker. They don't have room for a wheelchair. They don't have room for all of this adaptive equipment. So those are the kinds of things that we're talking about, right?

Speaker 2 (13:28.29)

Yep, exactly. And you raise a really good point about like teletherapy and the access, how that improved access like for your clients. It really did. Yeah, and that's a great thing, right? Like we want to lower that bar to access. But the reverse of that also is like a patient who might not have internet access or consistent internet, right? Like, so this is a good example of how STOH are sort of positive and or sorry, not

they are neutral, but you can have these protective factors that are positive or these risk factors that can be negative in looking at the same sort of situation.

Right. And I think it's important, you said earlier about for the SLP to screen and make sure that you're doing a good evaluation of this family because sometimes those questions can be difficult to ask. hundred percent. And a lot of times parents may not be, I mean, they may be embarrassed to say, hey, I don't have money. I don't have a car. My car is broken. I don't have gas money. I have a car, but I don't really have gas money this week to come for the therapy appointments. And I remember that a lot.

because in Alabama it was set up to where they would have to come into our facility at least once a month or once every six weeks. And then we would go out there the other times. But it's really interesting as I've started going through this after we decided on this topic and I've been starting to think about those specific situations. what are some interventions? What are some things that we can do? We've talked about what they are. We've talked about those key factors. But what can SLPs do to improve that?

to help our families have better access.

Speaker 2 (15:07.288)

Sure. Yeah, that's a great question. And I'd like to sort of start with, like, we don't expect SLPs to, fix housing insecurity or health care access on their own, right? That's not what's expected of the SLP or just the individual in any setting, whether it's a school, a health care facility, a private practice, anything like that. know, but really what you can do is start by just sort of talking about SDOH. And you're going to hear me say that.

a lot of different times throughout the rest of this conversation. But screening for SDOH is a really big intervention that you can implement that makes a huge difference that's, you know, for the most part can be relatively low effort just depending on your facility. And I don't mean effort in the sense of like it's like a lazy intervention or anything like that. I mean more like you will get a lot of bang for your buck in sort of screening for SDOH.

That also comes in just having that open line of communication and building that rapport with the family. So I think a lot of SLPs are probably doing that and they don't even realize they're doing it.

Exactly. And some examples I had for that were like starting to build STOH-related questions into like your intakes and case histories. Just, you know, sort of asking patients about that, initiating conversations with them. If you work in a facility where you can do like a QI project to employ a formal STOH screening tool or questionnaire if you don't have one already, you know, that's a great option.

and note any SDOH information shared by other members of your patient or client's care team, and review their documentation and other notes that other members of the team are writing so you can kind of be aware of what's going on in their lives. In addition to that, I also like to recommend making referrals and connecting clients to resources. So if you know that the patient has a social risk or an unmet social need,

Speaker 2 (17:07.586)

you know, working with a caseworker or social worker, you know, to kind of connect them to some resources. Or there is a really great tool on our website, I think it's called findhelp.org, where you can put in your, if that's not the correct length, then it'll be on there and I can point to it for everyone. But what you can do is put in your patient or client's zip code, and it will bring up some resources that can help bridge some social need, unmet social needs.

Yeah. And I'm thinking about in the school system, a lot of times, I think the biggest impact that I see are for kids who need glasses. You know, they fail the vision screen and their parents don't have the money to get them glasses. And it's heartbreaking. But in the school system, we typically have those resources, like you said, you know, there are teams of people that will come out, there are doctors that provide those services. I have had, I think this last year, I had two kids on my caseload that had, they couldn't see.

And they would say, I mean, they were middle elementary, so they were old enough to understand and say, I can't see this. I can't see the text. I can't see the board. The teachers were, you know, we're moving them closer to the room. And I noticed it when they came to speak, because they were getting like right close to my computer. And I was like, are you having a hard time seeing that? So I just sent home a quick screener permission and the nurse pulled them and screened them. And she was like, they failed miserably. And then, you know, six months later, school year's over and they still don't have their glasses.

And it's so heartbreaking. It's so hard. And we often, you we take for granted that, you know, not everyone has the same opportunities and that's name access.

Mm-hmm. I keep fixing my glasses here because they're new and they keep falling off my face and like I'm taking that for granted, right? That like I was able to go out and buy a brand new pair of glasses because I wanted a new pair of glasses. Mm-hmm. Because I was bored of my old ones.

Speaker 1 (19:04.12)

You just want a different color. And it's so hard to, think, you know, I keep going back to that early intervention situation that I was talking about. And I remember us going out for the childhood, the family lived in a really small apartment. I think there were multiple family members living there. So there was stuff everywhere. And I remember us going out as a team and rearranging, asking them, hey, do you mind if we help you rearrange your living room just a little bit? Because we had to get some adaptive equipment in there, you know, adaptive seating, walkers and those.

that sort of thing. And we just, you know, all of these needs that the child had and the family wanted them and they were trying their best to get them and they were doing all of the right things. But just physically in their home, there was no room and the child's, you know, bedroom was upstairs. And so you've got a mom that's trying to carry this child who's getting bigger and bigger every day. And we talk, I remember talking, having that conversation, the physical therapist saying, you know, there are two now.

But in five years, they're going to be seven. then they're going to be 12. And then they're going to be 16. So we really need to take a look at where you're living because how are we going to get them? You're not going to be able to carry them upstairs forever.

Exactly. Yeah. Yeah. And that's a really great point about like neighborhood and built environment because that's kind of what your house looks like, right? And what your neighborhood is like and how you navigate that. But then there's also that sort of economic stability piece of it too. Like, can you afford to make changes to your home? Like I live in a one bedroom, one bathroom condo in a city. And if something happened, you know, to myself or my husband, like,

we can't change the way our condo looks. And that's a huge piece of things that you don't realize, like, yeah, we're homeowners, right? We have this, that's a protective factor, but how that can so quickly slide into a social risk and an unmet need. And I love you kind of talking about collaborating with PT because I think interprofessional practice is so important when it comes to SDOH because it really requires all of us to kind of work together and sort through what's a risk.

Speaker 2 (21:14.594)

what's protective, what may turn into an unmet social need and kind of where can we bridge that gap for patients.

Right. And I never really understood the importance of, you know, in early intervention, they do the bagless model. So they don't want us taking all of these toys into the home. We want to go, we want to send our therapists into that home to use what they have because we don't want to take these toys in there that they don't have access to. And even something as simple as a cup, you know, an adaptive cup, maybe when you're trying to transition from, you know, a bottle to a sippy cup.

they don't have a lot, some families just don't have money aside to purchase that cup. And then I can't tell you how many sippy cups I bought. I mean, I bought so many sippy cups over the years when I was in early intervention and just trying to provide them with the basics that they need. it's not even the extras that we all probably take for granted. It's really hard. So it's so important for SLPs just in, you know,

to consider these social determinants as you're going in and asking those tough questions. And that's where it starts, like you said. The number one thing we can do is to get to know our families, know what their situation is, know what kind of support system they have. And I know that that's done extensively in early intervention, but in other settings, it's not. Like I said, for me as a school-based speech pathologist, that's not something that I consider.

But do I see the effects of it? Absolutely, because I had several kids that needed glasses and didn't get them all year.

Speaker 2 (22:53.612)

Yeah, yeah, for sure. I mean, I can give an example of like when I worked in the NICU, yeah, I was at a pretty big community hospital that was in, you know, like a relatively economically flourishing area. And then my hospital system acquired another hospital that was in a different area and just had a whole set of patients with different SDOH and just

seeing how unprepared we were to manage that difference. And one of the biggest things was that the parents who were living in that area were 45 minutes away from our hospital and there wasn't consistent public transportation that could get them to us. And a lot of them didn't have cars or a way to get there. So they just had a preterm infant or a sick infant. They can't get to the hospital to visit them.

They have to get back to work soon. And we were just really unprepared to manage any of those issues. And it took a while for sort of the rest of our staff to catch up to be able to help sort of meet those unmet social needs for those patients.

Yeah, and then you just have to pivot. have to reconvene and be like, what are we going to do? We've got these patients that have these needs, but they can't access us, so what do we do? What do you do at that point? How did you guys pivot and adapt to that situation?

Yeah, that's a really good question. We worked hard to make sure that when parents were able to visit that they were able to hold their baby, that the staff that they needed to meet with was available to see them, whether it was, you know, later at night. There were a couple times where I was working with some of those babies on feeding.

Speaker 2 (24:34.962)

And I would stay later into the evening to be able to be there to meet with the parent. But we also worked with our hospital's charitable foundation to get some ride share gift cards so we could help them sort of afford to be able to get transportation to us. And our social workers also helped set up rides for them to take that stress off of them that they didn't have to do it with themselves.

That's so interesting that you said the ride share because a light bulb went off and I was like, wait a minute, I started working in 2000. I was starting early intervention in 2000. I graduated in 96. We didn't have ride share back then. So it was trying to set up a taxi, trying to set up a cab, something like that. And that's not always easy. And it would be so easy now for me to just be like, okay, I'm going to send an Uber to you and just getting in on my app and sending it to someone or having.

maybe not your personal one, but the facility having that ability to do that, I think would be so much easier than it was back in the 2000s when there were no iPhones. know my daughter's like, wait a minute, there was no iPhone in 2000? I'm like, no, girl, things have changed so much. Stephanie, this has been so amazing. This information is great. What advice do you have for SLPs? What would you tell them about SDOH and how they can...

and help their patients access their services.

Yeah, I love this question so much and I'm going to repeat what I sort of said earlier. Just start talking and thinking about SDOH. Talk to your colleagues about it. Bring it up with the IPP team. Talk about what sorts of protective factors you're seeing with your patients. What social risks are you noticing amongst your caseload or what consistent unmet social needs are you seeing in the populations that you're working with? And this is

Speaker 2 (26:29.932)

This is challenging, but I want to kind of say, find a way to talk to families that offer sort of like mutual comfort for both of you, because this can be a really challenging conversation.

Right, and that's what I was thinking about when we decided this would be the topic for the podcast today. I was like, those are very tough, difficult, uncomfortable conversations and questions to ask, but we have to do it as professionals.

Yeah, I often started conversations with parents by saying, we ask everybody these questions. There's nothing different about you. It's just, you know, to see where we can help you. We have a lot of resources. And I would often give them an example from myself. You know, like I said before, I'm comfortable talking about that stuff. People aren't. And that's fair. And like, that's respectable. You don't have to. But sometimes, you know, letting them kind of...

getting on their level and letting them know that this is a safe space and that the information that they share is safe with you and that you want to help can sometimes sort of open the door to having that conversation.

Yeah, and I would say I would add to that understanding the culture of the family. Because not all cultures are like ours where they're that open to talking about those personal type of questions. So understanding what the culture is of the family that you're working with.

Speaker 2 (27:39.246)

100 %

Speaker 2 (27:53.112)

Yep, that is a fantastic point and I'm really, really glad you brought that up.

Yeah. So this has been awesome. I've learned so much. I do want to pick your brain. Maybe we'll have you back on and talk about the you and the dysphagia and the swallowing, all that. It's fascinating to me. But we also, I wanted to ask you, are you going to be at ASHA this year? Oh, that's so exciting. I'm going to get to meet you. I'm excited. So this is ASHA's centennial year coming up in November in Washington, DC. So to all of our listeners, AMN is going to be at Booth.

Yes.

Speaker 1 (28:27.63)

3312-3312. So write that down Stephanie so that you can come find us and meet with us. I know we're going to be doing a podcast closer to Asha talking about all of the wonderful things that are going to be there for this centennial year. So great, Stephanie. Thank you so much for joining us today and for all of this amazing information. We're going to have all of the links that you talked about from Asha and any other links that you would like to provide us. We're going to have them linked in the podcast.

But thank you guys so much for listening and you guys have a great day. Thank you for tuning in to SLP Full Disclosure. You can learn more about this episode and our show on our website at amnhelfcare.com. If you enjoyed this episode, share it with a friend and subscribe to our show on your favorite podcast platform. You can also find show updates and SLP opportunities on our Instagram at amnally. Special thanks to AMN Healthcare for making this show possible.

See y'all next time.

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