Social Determinants of Health: Using Consumer Insights to Move from Why to How
The social, economic and physical environment in which a person lives is widely recognized as influencing their overall health and well-being.
Social determinants of health (SDoH), or the non-medical factors that impact one’s ultimate health, are at the center of a host of policies and initiatives coming out of state and local governments, health systems and health plans, and even the commercial sector.
Addressing SDoH is about leveraging people and technology to shift from traditional care models to ones that support a complete health strategy.”
The CDC supports a menu of programs and assessment tools aimed at addressing SDoH. In 2017, 19 states required Medicaid managed care organizations to screen patients for social needs. Beginning in 2020, CMS plans to begin reimbursement for SDoH-related benefits such as meals and transportation. And Humana’s “Bold Goal” initiative is screening half a million people for social barriers to health. Outside of the healthcare sector, HIPAA-compliant products and partnerships such as that of Uber Health and Ambulnz are already in the market working to alleviate barriers to care.
The growing list of SDoH-related programs is diverse in approach and size, but what has become consistent is healthcare leaders’ understanding that to deliver better health outcomes, social determinants must be addressed.
While adoption of value-based payment models has been slower than predicted, risk-based initiatives are not going away, requiring organizations to think strategically about who they partner with outside the walls of their facility. Moreover, the collective impact of such partnerships may ultimately hold the biggest return on investment as organizations seek to be part of creating a healthy community as well as healthy patients.
Consumer and Population Insights
For providers, the complexity of social health determinants paired with a varying list of organizational priorities makes it hard to know where to focus. Determining the “who” and "what” of SDoH programs begins with a data-driven understanding of an organization’s existing population.
For organizations just beginning to leverage SDoH data, start small and strategically by capturing and addressing transportation and home support risks as part of inpatient discharge planning. Or, look to a known high-risk segment such as the diabetes population and begin examining underlying factors from medication adherence to housing that might be impacting that group.
Food security and quality of housing, two environmental aspects of SDoH known to have a strong link to health, are common areas of focus for healthcare organizations. Montefiore Health System in the Bronx boasts a 300 percent ROI on its housing assistance program. Atrium Health and its partners are investing $50 million in a holistic housing development, and provider-sponsored food assistance programs are emerging across the U.S.
Understanding market-specific consumer population issues, including the prevalent environmental social determinants, is also leading many health systems to focus on increased access to behavioral health services, mobile clinic offerings and telehealth virtual offerings as part of overall growth strategies. Shifting an organization’s mindset around consumer insights, including SDoH data, can inform the way organizations generate network expansion and create services aligned to consumer preferences and needs.
Strive for Collective Impact
No organization should initiate new programs to address SDoH without first evaluating their community for potential partnerships. Collective impact, or solving complex problems through cooperative, cross-sector collaboration, should be the goal.
For example, ProMedica, a not-for-profit healthcare system based in Ohio, co-founded a coalition expressly dedicated to addressing social determinants threatening the health of their population. NCH Healthcare System in Southwest Florida reported significant ROI after adopting the Blue Zones Community approach which unites workplaces, schools, grocery stores, faith-based organizations and others around improving the health and well-being of a community.
As value-based care continues to drift from the exception to the rule, clinical outcomes and an organization’s subsequent financial success hinges on partnerships and solutions designed around collective impact. Eventually, more healthcare providers may develop shared savings agreements with outside organizations to ensure everyone is invested in a program’s goals and outcomes.
Technology Aids in Addressing Social Determinants of Health
For many years, effective low-tech strategies such as community health workers, community needs assessments and questionnaires have been staples for organizations seeking to address consumers’ needs beyond medical treatment.
Today, organizations are tapping into technology-enabled solutions for analyzing consumer vulnerability to high-risk social determinants, linking to available social programs and improving patient activation. Tools such as Waystar’s Whole Patient Insight® and Pieces Decision Sciences provide patient-specific insights into social determinant risks and predictive analytics to help clinical teams make real-time decisions about patients’ needs for housing, transportation, food or other factors contributing to their health outcomes. Companies such as Insignia Health and HealthLoop provide tools to facilitate health education, patient activation and improved self-management.
Electronic health record (EHR) systems such as Epic and Cerner also continue to advance their functionality to address SDoH with enhanced data collection, predictive insights and other population health capabilities.
Ultimately, addressing SDoH is about leveraging people and technology to shift from traditional care models to ones that support a complete health strategy.
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