Population and Public Health

Leveraging Social Determinants of Health Data to Improve Accountable Care Delivery and Gain a Complete Picture of Patients’ Needs

Leveraging Social Determinants of Health Data to Improve Accountable Care Delivery and Gain a Complete Picture of Patients’ Needs #NHITWeek

During National Health IT Week, champions from across the industry are uniting to share their voices on how health IT is catalyzing change in U.S. healthcare. The following post from a National Health IT Week Partner is one of the many perspectives of how information and technology is transforming health in America.

Andy Aroditis

Access to a complete picture of a patient’s health is key to enhanced clinical care coordination, reduced duplicate medical testing and procedures, improved billing accuracy, increased patient safety, and greater patient and provider satisfaction. This requires patient data matching and cross-system interoperability that extends out into non-clinical or traditional healthcare settings. Because the health of individuals is heavily influenced by socioeconomic and behavioral forces, collating a comprehensive view of one’s needs is critical to achieving value-driven, community-based outcomes.

Referred to as social determinates of health (SDOH), providers can harness meaningful insights into the well-being of their patient populations to deliver high-quality care, while minimizing risk. Since social determinants now make up the majority of factors contributing to population health, plans and providers are seeking to build a total picture of a patient to offer intervention and support. For example, hospitals can leverage SDOH data, which includes information on housing, income, crime, education, transportation, domestic circumstances and food insecurity, to proactively identify and treat those most at risk before they are forced to be admitted into inpatient settings for care.

Stakeholders are increasingly recognizing the importance of SDOH influences because of how they affect outcomes. While the impact of non-clinical risk factors outside the health system is significant, they have been relatively difficult to assess and measure.

Approaches for Weaving Social Determinants Into Population Health

Addressing social needs is increasingly necessary in the hospital or emergency care setting given their relative importance to ongoing access to care. However, embracing these needs as a key component to improving outcomes still comes with its own set of challenges, such as how to define the problem, collect and share data and form community partnerships with likeminded goals.

The primary reason why social factors are considered to be so impactful is because only about 20 percent of health outcomes are determined by clinical care. The remaining 80 percent is determined by non-clinical factors, most of which are influenced by geography and socioeconomic conditions. This explains why communities with poor overall health status can actually overshadow a thriving health care system that surrounds it.

Among potential solutions at the provider level, policy and process approaches have been developed to address the breadth of social needs. For instance, one of the initial steps to assessing social determinants is through screening and information gathering. Without this knowledge of populations who might be most vulnerable, it is difficult to leverage any potential services or assistance for at-risk patients. Hospitals and other providers who want to address SDOH have been encouraged to utilize the Center for Medicare and Medicaid’s 10 question screening tool designed to identify unmet needs in five core areas – housing instability, food insecurity, transportation needs, utility needs and interpersonal safety. Studies are showing that many hospitals do screen for social needs, but the data collected isn’t always shared easily among departments or made available to everyone involved with patients.

A second method providers can implement to address underlying social conditions is through navigation services that assist patients in accessing community services. Similarly, providers might also engage with community stakeholders to align their services more closely with the needs of local patients. Investing in health-related social needs remains challenging since providers aren’t guaranteed a return on investment. In addition, at many hospitals, initiatives are often unconnected, which can dilute their effectiveness. Consistent measurement of these initiatives is often even more important since overall activities should be tied to health outcomes, cost outcomes and patient experience.

What makes social determinants difficult to address is providers expect some return on investment from programs and many solutions have difficulty offering concrete results. In addition, the lack of adequate or dedicated funding in many cases makes addressing social needs even more challenging. Deloitte published a report that found 72 percent of participants do not currently have budget for all the populations they would like to target.

Interoperability and Patient Matching Bridge the Gap

Deploying analytics tools to social needs data is showing signs of promise, particularly as organizations seek to reduce the likelihood of readmissions. When screening for social needs is combined with one’s medical record, this critical data can be more readily collected, stored, accessed, and put to use across many settings and locations.

Tools that offer reliable patient ID matching and medical record management, facilitate the ability to track individuals uniquely across a diverse set of systems and facilities to enable a clear and holistic view of a given patient and promote a more consistent patient experience. This important step in meeting social needs gives providers the opportunity to find potential gaps in care by seeing the entirety of a patient’s medical history.

For example, at California’s San Mateo County Health System, incorporating SDOH data into its electronic medical records (EMRs) with use of patient matching technology has helped to reduce “epistrophic” events among its vulnerable population. To help meet the goals of value-based care and to effectively follow individuals across disparate clinics and public health agencies, health IT leaders at San Mateo are leveraging such data as reading level and water purity into its care services.

Access to complete and accurate patient data that flows freely across boundaries is a catalyst for improving community health and well-being. Incorporating social determinants data into EMRs allows care managers to access and apply data-rich insights into a patient’s treatment plan. By complementing extensive clinical data found in EHR systems, SDOH enables more informed care decisions.

Putting SDOH Data Into Action

Exerting control over social determinants isn’t the end goal of providers, but to offer interventions outside of clinical care to improve value-based population health. Screening and intervention are logical steps in assessing social determinants but knowing how to put this data into effective use remains a challenge. So far, solutions have been mainly focused on intervention and engagement with limited to moderate success and no guarantee of a return on investment. Until more innovative solutions or partnership opportunities emerge, reliable patient matching and interoperability tools will be an imperative foundation to painting a more complete picture of an individual and offering insight into their ability to benefit from specific care plans.

By building social needs into the patient data capture process, providers can track individuals across the care continuum, thereby improving the likelihood of care plan success and prospering in an era of increased accountability.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

Join Us as We Reimagine Health Through Information and Technology

At HIMSS, our vision is to realize the full health potential of every human, everywhere. Be part of the community that’s transforming the global health ecosystem with courage, curiosity and determination.

Be part of what’s next for health