Imagine two patients with the same medical condition, receiving the same treatment from the same provider. Yet, one patient recovers quickly while the other struggles with complications and setbacks. The difference? Social determinants of health (SDOH), such as access to healthy food, transportation, and safe housing. According to the National Academy of Medicine, SDOH account for up to 80% of health outcomes.
Recognizing the need for greater health equity, the healthcare industry has — in line with the corporate sector’s focus on equity and inclusion — acknowledged the significance of collecting, standardizing, and analyzing SDOH data. The ideal goal is to provide every individual with equal opportunities to attain their full health potential, regardless of factors such as race or ethnicity, age, disability, and gender identity. This recognition aims to drive efforts in reducing disparities among disadvantaged groups and promoting equal opportunities for all.
In pursuit of health equity, last year, the Centers for Medicare & Medicaid Services (CMS) rolled out a framework that details their 10-year plan for improving health equity, health coverage, and health outcomes. Their top priority is the collection of SDOH — specifically focused on chronic and infectious diseases that are known to disproportionately impact underserved communities.
For patients who may be at higher risk for illness, such as those enrolled in Medicare and Medicaid plans, SDOH plays a particularly crucial role in their health outcomes. To provide timely and customized care management for these types of patients, providers can lean on analytics to create a more holistic view of their patients’ health.
Unveiling the Data
Health information technology (health IT) is instrumental in accurately tracking and monitoring SDOH metrics. Through electronic health record (EHR) systems, providers can collect and integrate SDOH data alongside clinical data. This integration provides a comprehensive understanding of patient populations and enables the identification of patterns and trends related to SDOH.
In addition to EHRs, provider organizations can also collect individual-level SDOH data via health assessments and surveys, or community-wide information by leveraging publicly available datasets such as census data.
However, challenges arise due to the lack of standardized data collection methods across healthcare organizations. To address this, providers should establish consistent approaches to data collection and integration. Partnerships with community organizations and the adoption of standardized data collection tools can facilitate this process.
A More Complete Picture of Patient Health
Having easy, organized access to SDOH metrics and the ability to track them accurately for each patient significantly improves the care providers can deliver. By leveraging analytics, providers can identify high-risk patients who are most vulnerable to poor health outcomes due to SDOH. Risk stratification models, incorporating both clinical and SDOH data, aid in identifying these patients.
Once identified, providers can develop targeted interventions tailored to the specific needs of each patient. Collaboration with community organizations, public health agencies, and other stakeholders allows for the development of interventions that address the unique SDOH challenges faced by patient populations.
For example, partnerships with food banks can provide access to healthy food options in underserved areas, and collaboration with transportation providers ensures patients can attend medical appointments. Through these interventions, providers address the underlying social factors affecting health outcomes and ultimately improve the overall well-being of their patients.
Connecting the Dots from Provider to Health Plan
Accurate data on patients’ determinants of health not only benefits a clinician’s ability to provide better care for their patients, but also enables health plans to streamline their roles. By leveraging analytics, health plans can gain insights into the SDOH factors that significantly impact health outcomes. This information allows for more effective resource allocation, ensuring that interventions and services are appropriately targeted.
Health plans can collaborate with providers to identify at-risk populations and allocate resources accordingly, reducing costs associated with preventable hospital readmissions and emergency department visits. Streamlining roles through the use of accurate data improves the efficiency of healthcare organizations and enhances the quality of care delivered to patients.
Evaluating Success and Inspiring Change
It is essential to monitor and evaluate the outcomes of SDOH interventions using analytics. Tracking metrics such as hospital readmissions, emergency department visits, and disease progression enables providers to measure the impact of their interventions accurately. By continuously analyzing the data, providers can identify successful interventions and areas for improvement. This iterative process allows providers to refine their approach to addressing SDOH, leading to better patient outcomes over time.
Leveraging analytics to address SDOH is a powerful tool in improving healthcare outcomes. Health IT enables the collection and integration of SDOH data, while analytics provide insights into the factors impacting health outcomes. Easy access to organized metrics and accurate tracking allows providers to develop targeted interventions that address the unique needs of patient populations. Collaboration with community organizations and stakeholders further strengthens the impact of these interventions.
