In this episode of the Your Health University Podcast, we dive deep into one of the most pressing topics in patient care: Social Determinants of Health (SDOH) and how they shape patient outcomes. Host Jamie Preston is joined by Carlos Heyward, Jennifer Kistler, Kim Metze, and Rebecca Dillard—leaders from the Your Health Patient Experience Team—to discuss the hidden barriers that impact patients beyond the exam room. Together, they explore: ✔️ Why trust is the foundation of patient care—and how to earn it ✔️ How healthcare professionals can listen between the lines to identify unspoken struggles ✔️ What it takes to move from recognizing challenges to actively solving them ✔️ Why empowerment, communication, and follow-up are critical to real healthcare change ✔️ How social workers, providers, and community health workers can work together to break barriers This isn’t just another conversation—it’s a call to action for healthcare professionals to rethink how they engage with patients. Because when we listen differently, we care differently. 🔹 Don’t miss this insightful discussion—it could change the way you approach patient care for good.
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Welcome to the Your Health University podcast, formerly the LTC University podcast, where we explore how education, innovation and compassion come together to create a better patient outcome. I'm your host, Jamie Preston, and today we're tackling one of the biggest challenges in health care, the social determinants of health, the hidden barriers that impact our patients long before they ever step into an exam room or our provider meets them at their home,
at your health we've been talking about this for a long time, because we know that real healthcare goes beyond symptoms and prescriptions. It's about trust, connection and truly understanding the full picture of a patient's life. Today, I'm joined by an incredible group of experts from our your health patient experience team. That's Carlos Hayward, Jennifer Kistler, Kim Metz and Rebecca Dillard, together, we'll dive into why Trust is earned, not assumed, how we can listen between the lines to recognize when patients are struggling, and how we can move from identifying challenges to actually solving them. This isn't just a conversation. It is a call to action, because when we change the way we listen, we change the way we care. Let's jump in, guys. Welcome to the podcast. Thank you. Thank you, Jamie. Yeah, it's great to have you now. Thank you, Jamie. I will. Yeah, thanks the this is the most. This is these are the most guests we've ever had in one episode. So I'm excited to try this out today. So those of you are listening, we we've This is, usually we don't have more than two guests, but I'm excited about this. I'm excited about what you guys have been doing over this last over a year now, working on patient experience at your health, and it has really changed the game and made a huge culture shift. And it's really admirable, and it's exciting, what you guys have been able to accomplish over that year, which is really impressive.
So let's just jump in here. We're going to be talking about the social determinant of its health, as you see in notes and emails. SDOH is kind of how people
refer to it in writing, but breaking barriers building trust, let's go beyond the systems when we shift from treating symptoms to understanding the broader life circumstances of our patients, what transformations do you see in patient outcomes? And I'll let whoever wants to jump in there, jump in.
I'll jump in.
I think there is the full understanding that we can't just medically care for a patient's needs, we have to holistically be able to address the issues that impact their health. And the fact that Medicare has put such an emphasis on social determinants of health really gives it a lot of prominence and respect and attention
from the medical community, which is good,
yeah. And, you know, I would add to what Jennifer said, Jamie, you know, like you said, over the last year and a half, we've been working primarily on patient experience. We had to do that by starting off with working on communication between colleagues.
What we've realized, I think Jennifer just alluded to it as well as that
we can't do very much at all with our with our patients if they don't trust us. And I think if we go into a house and we say, Hey, you have diabetes, and just treat the diabetes, if we're not really talking to our patients and listening to them
asking all the aspects that impact their their well being, which is not just the disease itself, it's what has created the disease or what has prevented them from being able to take care of themselves, we're not going to earn their trust. So it's very important that we find out everything about the patient, not just their medical diagnosis. Yeah, absolutely. And while you're we're talking about trust. Trust is earn, you know, I don't think there's any other way to do it. And we, we all earn trust, and we have we let people earn trust in our lives. And it can't be assumed. Many patients feel embarrassed to admit they don't have food, transportation or stable housing. What strategies have you found effective in earning a patient's trust so that they open up about these deeply personal struggles because they are it can be very embarrassing.
Kim, I'm going to come.
Put you on the spot with this question, what have you guys been doing?
So I think, thank you, Jamie. I think that it goes back to what Rebecca was just saying, and that improving that communication, you know, with your patients, you know, and being empathetic and being authentic, those are things that we really focus on in the workshop is things that we're, you know, helping our colleagues with to learn, because they're all skills that we have, but we, you know,
sometimes they just need brushing up, you know, but being empathetic and really listening to your patients and having that communication and say, I'm, you know, I hear you.
I understand that this is difficult for you, but let me help you. Yeah, that's great, yeah, because it really it, and it's not overnight. I mean, I just don't think you can meet a patient one time and just have all the trust now, sometimes you know your you know, maybe it's a doctor, you know, and that person respects that person because of their title, but I think it's trust goes way deeper for them than that. Jennifer,
yeah, there were some definitions I was working on writing an article,
and there were some definitions that really stood out to me that reiterate the importance of trust, empathy. First of all, we're not selling widgets. Healthcare is a relationship. It's a relationship between a provider and a patient, but it's also a relationship with between the patient and the care team. And when I started looking at relationship, is in the way two things are connected, and we are connected to them, but we can't do anything unless they feel connected to us. And I just had to read this. I thought this was a spot on definition of trust, to believe that someone is good and honest will not harm you, and that something is safe and reliable, and if they feel that trust, they're going to value what we're trying to do for them, how we're trying to help them, and be more compliant.
Yeah, absolutely, and I think that's huge, because
I'm guilty for not taking medicine when I was supposed to, or forgetting and you know, in it that trust really, you know when you respect and you trust the provider. I mean, it all plays a part in that
100% so let's talk about listening between the lines. Because I think this is a, this is a skill that I think you have to develop over time. It's, it's being, you know, really inquisitive. And it takes real listening, you know, to do this. Patients often will drop subtle hints that they're struggling with the social determinant of health. How do you train yourself and your team to hear what isn't being explicitly said?
I'll jump in and say a couple of things. Jamie, we do talk about active listening a lot in our training and at orientation and and the visual that always give is, you know, the water falling on a brick, and the water bounces off the brick. That is not listening to understand. Listening to understand is the water falling on a sponge and the sponge absorbing what's falling in. So we really have to to listen. And I think one of the best ways, one of the things that I've really learned over the last year, over the last year is to be truly present when we're with the patient, even if we're on the phone, no distractions. Don't have your phone out. Don't be carrying on a conversation on teams while you're with your patient. Look them in the eye. That's That's how they feel heard and listened to it's just truly being very present with them in whatever capacity you're using to communicate with them. Carlos give us your thoughts when we are listening, I guess in say between the lines.
Also pay attention to your patients and
kind of pick up on things that are different with them.
You know, we could have we, we all have the same patients. We talk to them every month at least. And if you notice that,
let's say, for me, let's say we're sending the medications to a different house every other month. There's something going on with housing there,
and with that, of course, they're not going to be able to afford, you know, paying for their medications, and most likely not being being able to afford food. So just kind of
pay attention to what you're doing in the computer, because sometimes just changing address can that should trigger something, and you may need.
Ask those follow up questions, but like, Hey, are you know, how are you doing?
We've noticed that you've changed addresses a few times. Is everything okay? Do we need to get a social worker out there?
Sometimes it's not about what they say or what they don't say, but it's sometimes it could just mean the keystrokes.
Yeah, that's a great point. Carlos huge about the change of address and so interesting. I think that really shows how important it is that the care teams are talking to each other. You primarily are involved in pharmacy, and you've picked that up. You know, maybe a social worker wouldn't pick that up because they're not mailing anything to the patient. So I think that's, that's an excellent point, and that's a social determinant. I don't know what the Z code is exactly, but you know the homelessness or
one of those codes that falls in that range, yeah. And I think when I hear that, I automatically think, is this going from different families houses, because the needs of the patient may have changed. And, you know, we have a patient that receives remote patient monitoring, and he literally moved from one region to another, so there was the coordination of, okay, what provider is going to pick up, care what? And we really do have to pay attention to all those details. Yeah, and let me, I think what Carlos is saying too, is you have to pick up on the clues, look for the cues. I never would have thought about, oh, now this person's address has changed four times in the last quarter, you know, or something. I would have never thought of that. You know, you really have to be inquisitive and really looking deep into that. And let me say this about listening. So we're talking about listening. Carlos is the best listener you will ever find. I saw Carlos listening to somebody who they weren't happy. Let's just say that this person wasn't happy. And I sit, I watched him listen to this person for over an hour like this wasn't a patient. So if some of our leadership thinks that Carlos was doing that on billing time, he wasn't, but, but it was, it was after hours, but I saw him listening intently to this person, really hearing them, and made things so much better. Sorry, I had to just give you, give you your flowers there, Carlos, because you are Amen. We agree. Yes, yes, agree. So your health is very data driven. We have gobs of data that we use, and it's part of those clues that you're looking for. You know, when you're using that data identifying social determinants of health related challenges is just the first step. What needs to happen next to ensure patients get the resources they need. You know when you're looking at that data, what? What does an ideal patient centered response system look like?
Well, from the care management program standpoint of community health integration, the nice thing is that anyone can pick up on a need and insecurity, and once they communicate that with the provider and the care team, the provider diagnosing that appropriate Z code opens up the possibility for us as your health to
be able to utilize the community health integration program where we're going to have a social worker that has every resource and sophistication and ability to be able to come up with a plan of care that helps us hopefully resolve the insecurity that our patient is having, and that's pretty That's pretty huge, that Medicare is just really pushing this because they know how important it is.
I could add a little more detail. Just as an example, this week, Jamie, we had training with the after hours team, and those are the folks that come on. Some come on at four o'clock. Some come on at seven. We have a history of patients calling us at 3am because they need somebody to talk to. So that after I was team is very, very familiar with our patients. So April and I, April Dawson, who's director, director of that team, asked, uh, Anna crisp, who is one of the folks tasked with pushing the social determinants of health initiative, we asked her to join the call. And so the process that that we came up with on that call is when they find out, for example, at a patient thought her son was going to deliver groceries Monday, he didn't. The patient didn't have food for three days. The after hours team found out. So their process now is to get on Athena and look and see if that patient has an upcoming appointment. If they.
Do they're then to put that social determinant of health? I can't. I'm not Athena savvy, but I believe they put it in the amp. If I'm wrong, yes, Jennifer's nodding her head. I'm right. So, so there's, there's that immediate notification, if they don't have an upcoming appointment, that they're sending a patient case to the team, not just a provider, but to the team. So when you're asking what the steps are once we identify that's just an example of one of the ways that we're identifying it and then taking action. And I believe that's probably happening on various care teams, yeah, and most primary care companies don't even have social workers. You know, we get the calls. Trish answered the phone and a gentleman said,
Our power is out. We're cold. We need a generator. We don't know when it's coming back on. And to be able to say, I need to tag in the social worker is a huge I mean, that's, that's a resource that a lot of other health care organizations don't readily have.
Yeah, that's such a great point. And I think that is the beauty of this system that you guys have been part of putting together. And it's, it's just, it's just, it's beautiful when it all works together. It's never perfect, but it's beautiful when it can identify those things and it has those systems built in the data that you're looking at and that even the system, the data and the systems can help you identify those things. It's just really neat. And thank goodness we have those social workers. I got a little tiny taste of that back when we had the storm in Greenville back, you know, and Rebecca was texting me, saying, Hey, do you need a generator? I can send my daughter over, you know, because we didn't have power. Luckily, we had power when we got home. We had quite the week that week. So,
you know, when you don't have some of those things, those things that are just you don't, you just take for granted. It's so important to have those systems built in.
Let's continue talking beyond the walls. Because, like we all work in offices, our providers, thank goodness. A lot of them work in the home. They work via telehealth. We have some that work in clinics, you know, across the state and South Carolina.
But great health care doesn't stop when a patient leaves an exam room or the provider leaves the home. What does it look like when everyone providers, community, health workers, social workers, and even non medical staff? And I think that's really, really important as well, because, you know, especially if you're interfacing with the patient, or regardless, you know when you have that, how does, how do those things come together to address those social determinants of health challenges holistically,
um, I can, I can say
it also has to do with the last question, too,
that the care team knows exactly what we offer. We're not just primary care. We have a lot of ancillary services available, and if everyone on the care team knows what we have, I think we'll be able to help the patients a lot better.
Yeah, yeah. That goes back to something we've we've been preaching since last January, shared knowledge
of each other's roles and an understanding of what we do. Carly's is absolutely right. Yes, you know, needing the right hand, needing to know what the left hand is doing, yeah, and share knowledge of the company, period. Yeah, if you don't know what we can do,
I mean, you're going to limit yourself on how much you can help the station.
I think about something really basic, like, See Something, Say Something. And I think we as a company, even Scott said it on a call this morning, we are a company that says, Yes, we're a company that says, How can we
and really wanting people to get absolutely uncomfortable, if they are like, our patient has a need, I have to figure out how to meet the need and having that shared knowledge and understanding how we can provide care for that patient, it's pretty, pretty critical. Yeah, yeah, absolutely.
So many times. You know, I think people providers myself. I remember when we worked for hospice, when we had the hospice company
years ago, and you would go into certain situations, I've been with providers to hotel rooms to see a patient, because this person had to go to a hotel.
Help room because of housing issues. I went for safety reasons, you know. And so you really see a lot of different situations out there. I mean, what the providers are like, Yeah, tell me about it. Our community health workers that are going to the home. I mean, as so many people, they understand, I don't do that very often,
but so many times you can feel not empowered, or feel like you don't have the resources or tools. A lot of frontline providers can feel powerless to address a patient's financial struggles, food insecurity or lack of transportation. How can we embed empowerment into the healthcare culture? So every provider, every community health worker, every social worker, feels equipped to make a difference.
I think we probably all have a pretty good answer there. Kim, did you want to say something? Yeah, actually, I did. I was gonna say,
you know, I think just having that training around recognizing the social determinants of health that patients have, or, you know, offering access, you know, food pantries, that sort of thing, but you know, just normalizing the discussions that you need to have with your patients and and getting them to open up, and just involving that in your routine care, with your patients, and that they have the time and the tools, and you know, to address all the non medical issues that they might be having
and they want and need mutual respect,
When you mentioned Jamie earlier about the fact that there are going to be like Scott used to joke and say he would see people going women with walkers getting ready to go into one of our clinics, and they would stop outside the door and put their lipstick on because they were going to see the doctor.
There are our patients that are kind of putting on the show, but the show is really about what happens when we're gone, and so being able to develop that relationship and
be able to develop that trust and make it feel like a safe space that they can say what's really going on and what the needs are. Yeah, yeah. I if I can back up both of them, I Jamie. I really like what Kim said about normalizing the conversation. I think that's critical
from every position at your health to normalize talking to patients about these, these things. It's, it's an uncomfortable conversation. And there's so many considerations that that we, you know, have to think about, what about culture? You know, do they there? There are some cultures who are not going to admit that they don't have food. They would never in a million years, admit that they don't have food. And, you know, I think about my own parents now,
you know who were my dad's at home getting full time care at home. And I think about my mom, who's, you know, in her late 70s. And I've been thinking what social determinant of help would apply to my parents. And I know my mom is super prideful, and she would say, not one, not one single one. But I can tell you one loneliness.
And you know, I just, I think having a conversation with somebody like my mom, you have to be very respectful, the mutual respect that you guys were talking about, and normalize casual like this is because we care about you as a whole person, not because we're nosy.
And that also reminds me of, I think we're having to
one thing. We're working really hard to have conversations with our staff that serve people in facilities.
When Scott was talking about
somebody he was having a conversation with that explained that his mother was in this, like, multi million dollar, super fancy,
continuous care retirement community. And you think, Oh, they've got everything to the nines, the food, the this, the that
the only place they had available to move her into was a memory care unit,
and she was not needing to be there. It was just a, this is and it was having real
effects on her. And, you know, we can't just look at something and say, Oh, well, they're in this beautiful place. You know, when you talk about Rebecca mentioned isolation, that is a huge thing you can you can feel.
Alone and isolated, even when you are surrounded by tons of people in a building or a facility, and we have to change the way and say, How can I improve this patient's quality of life? Yeah, yeah. I mean, I think of, you know, some of my own experiences with, like, with my mom, you know, who cared for my dad with Alzheimer's for, you know, five, four years, you know, somewhere around there,
and she had my sister, she had me calling her on a regular basis. Her sister was that showing up a lot, but there was a lot of loneliness there, especially when it got to those end stages. So, so it's not just about the patient, it's also about the caregiver too. Like, you know, I think realizing some of those things, you know, it got to the point my mom needed a break from answering the same question over and over again all day long, you know, so it, you know, I love that you said loneliness and recognizing that as a true social determinant of health, it really is. If COVID taught us anything, loneliness is huge in our culture and our world, and I think it's just so important.
Let's talk about reporting, because reporting isn't enough.
Clinical staff are often required to report issues related to abuse, neglect or extreme hardship. But what's missing in our current structure that prevents real change for these patients,
that's such a hard question. You can edit that out. You can edit that out. Feel like we need a social worker. But does anybody have a good answer for that? Well,
I think, I think a couple things.
I think first, when you talk about normalizing conversations, I think when we have staff that are not clinical and licensed to be reporters of issues like this,
if we send community health workers out, we need to make sure that when we see potential areas of abuse, that as a care team, we support and have the conversation and get that that social worker and that CHW connected to
take the protocol, like, to follow that regular process
that is to report something like that. I think that is something that can feel really scary and overwhelming. We have to have like we have to make sure that our staff understand we've got your back. We you know, we value your opinion, and when you see things, this is the process we're going to go through to be able to address that. So we need to build relationship and trust, even within our own care teams to be able to not have someone say, I'm not going to say anything
because I don't know what to do, or I'm afraid I'm going to get in trouble.
Yeah, there's always an answer, and I think that's key. Is relying on your team,
talking to one another, getting advice. Because, guess what, if you're maybe a new nurse practitioner, there's a nurse practitioner out there that's done it. They've been there, done that, and until you start talking and bringing those things up, Kim, you're, you're a nurse. You've seen some stuff, you know, speak to this issue.
Yeah, what
to answer your question? Jamie, about like, what I think is missing? I think it's the follow up piece. You know, we do the reporting, we take the necessary steps, but are you following up that the patient got what they needed? You know?
I mean, they could have never received the care or the resources that they needed to overcome that hardship that they're having. So in order to create that real change, I think that it has to be paired with that holistic approach that we were talking about that meets both their immediate needs and their long term needs. You know you can fix it now, or hopefully you did. But did you follow up?
Yeah, I'm so glad you said that.
We we have to follow up if we say we're going to call Meals on Wheels and we just make that call and leave a message, and they do nothing. We fail that patient
fail a follow up.
Is so important. And can I just say, I know you guys like I live and breathe and talk about this stuff all the time, but with community health integration, we're required to come up with a care plan specifically tailored to that insecurity that includes the intervention and the short and long term goals, which is like spot on for what Kim said, and constantly revisiting seeing. How is it working? What do we need to do? Insecurities are not like chronic conditions, chronic conditions, our patients will live with for the rest of their lives, but they don't have to deal with these insecurities for the rest of their lives.
Yeah. So good. Yeah. I love that you said that, Kim as well, the follow up, follow up, follow up, that's the hard part of healthcare, but I think a massive part of it is just follow up. You know, from that initial visit, it's all follow up, really, when you think about it, so that's huge. And that just backs up. Well, I was just gonna say the follow up
backs up the trust and continues to enhance the trust and nurture the trusting relationship that the patient has with us. Yeah, and can I add,
maybe also follow up with the care team for the person who witnessed, you know, whatever or thought that they witnessed something. You know, people go through different things in life, and it could be something small that triggered them,
and it may go, it can go in two different directions,
yeah, and that will, that will help develop the trust and
insecurity within the care team.
So good guys, right? Great great point conversation.
Let's close with this question. As we talked, we've talked extensively about social determinants of health and how to deal with them. A lot of this takes courageous conversations. They're hard conversations addressing social determinants of health require, requires difficult, sometimes uncomfortable conversations. How can we create a culture where providers and social workers, and, you know, our community health workers, anybody that's patient facing,
you know, have a compassionate and proactive they're proactive in navigating these discussions.
I think it starts with training, of course and and we can do conflict training and difficult conversation training. I think one of the most important things Jamie is for all of those people who are having those difficult conversations, to be to feel valued by their colleagues and by our organization. And somebody said this early, feel like we have their back, like we're going to support you. And as Carlos said, some of these things that they face may be very difficult emotionally for them. We have to support them. We have to support our colleagues with their emotional reactions to some of these things. I'd love to hear what everybody else is. I don't want to be the last one. Yeah. No, I sit there and think of what we teach and our patient experience workshops
asking open ended questions to draw and understand the needs seeking feedback.
It is so about really focusing on communication and
as well as just the shared knowledge of if I find out that there's an issue, I know what to do next. I think,
you know, it is just amazing.
What is it? The Six Degrees of Kevin Bacon. I feel like everything is the same way, but with our patient experience workshops and with what we're talking about, the relationships, the everything and the communication, they are valuable
to everyone, every day. Yeah,
yeah, they you know, I think always realizing a short bit of discomfort is worth what you get on the other side when it comes to helping somebody, and I think it's really important to lean into that, and that goes with employees and your coworkers having those difficult conversations when you need to have them going through that little bit of discomfort.
Or will pay dividends on the other side, because it will build trust, it'll it'll build courage in yourself to continue having those conversations. Kim,
yeah, I think
something huge that I would like to touch on is, you know, self care for our providers, compassion fatigue is a real thing. And you know, when you're addressing these issues that are affecting your patients, and you care about your patients, it takes a toll on you, so we have to, we have to care for our providers. We have to take care of our providers, and we have to take care of each other, yeah,
so true. Such a great point. And I, you know, I think we've all been there, you know, with compassion fatigue. It really is a a real symptom of doing the same thing over and over again and having the same conversations with the same people. And it can really weighing on your ability to provide care sometimes, and and recognizing it, and getting encouragement from your co workers talking about it, you know, is just massive.
I want to, I want to leave Rebecca with the final you know statement here, since she's, she's our patient experience leader, and we all, we all appreciate her so much and what she's done and bringing this team together,
you know,
you know, Rebecca moving forward, you know, give us the final word on Social Determinants of Health and why It matters so much to our patient experience, culture.
Thank you, Jamie for the last words, but I will say I couldn't do any of this without this. Also team, we work very well together, and each bring a unique aspect to what we're doing,
as we've said throughout this conversation, social determinants of health and those, those Z codes are just as important as any physical diagnosis. When we're caring for our patients, and when we're identifying all the things that are impacting our patient, our patients ability to live their best life, to have a good quality of life,
we're we're,
if we're identifying those, we're enabling the entire care team to give great care, holistic care. The patients feel trusted or feel respected. They feel heard, and they're engaged with us, and they need the engagement is key. If they're engaged in their care, then they're going to follow what the what the providers are asking what the social workers are asking, and we will ultimately have a better health outcome for those patients. 100% agreed. Jennifer kisler, Kim Metz, Carlos Hayward and Rebecca Dillard, thanks guys for all that you do for your health and the impact you're making.
I hear like a fight song. I think here so Cold Play, Cold Play. It sounded like a university fight. I thought you may be playing the, you know, the Clemson fight song. There for a second. I've got Die Hard, okay, yeah, I don't know so
but, but guys, thanks for all you do you really are impacting our patients, you know, through our providers, through our Community Health, or through our entire organization, and really is a testament you've, I've said this to Rebecca a million times, but you really have changed the culture at your health positively and made this thing something that's not going away, and thanks for all you do. And we really, really appreciate you guys. Thanks so much.
Thanks, Jamie.
If today's conversation has shown us anything, it's that healthcare isn't just about medicine, it's about trust, connection and listening to what's not being said. Our patients just aren't medical cases. They're people with real struggles, and when we take the time to understand their full story, we create a system where health care truly works for them, not just around them. A huge thanks to Carlos Hayward, Jennifer kisler, Kim Metz and Rebecca Dillard for their insights leadership and the incredible work they do every day. At your health, you're all shaping the culture where patient experience is more than just a buzz word. It's a movement. And to our listeners, this is your challenge. Be the provider who listens beyond symptoms. Be the case manager, the advocate who turns awareness into action. Be the person who earns trust one conversation at a time. Healthcare is a relationship, not a transaction. When we show up, when we listen, when we follow up, we make an impact. Thank you for tuning in to the Your Health University podcast. If this episode inspired you, share.
It start a conversation, and, most importantly, put it into practice, because better care starts with you and I, until next time, keep learning, keep leading and keep making a difference. You.