Using Social Determinants of Health Data to Improve Patient Outcomes

This blog post was originally published in Hospitals & Health Networks.

When we talk about social determinants of health (SDOH) and their influence on patients’ health status, we’re including factors like neighborhood, race, income, access to transportation and education level. We’re also taking into consideration what the home life for those patients looks like: What kind of family presence do they have? Do they have a supportive social circle? All these things can play a role in whether patients can sustain a healthy lifestyle and comply with the care plans set by their physicians.

Some studies show that up to half of a patient’s health status is determined by SDOH. Traditionally, health care providers who were paid on a fee-for-service basis may have had fewer reasons to address SDOH factors — at least from a financial point of view. Today, as the industry shifts to a value-based care model and as reimbursement norms are changing, SDOH factors are starting to gain traction.

Here, we look at tasks that health care providers should consider to get essential information to clinicians, care managers, social workers and community organizations, so that all parties can work together to drive improved outcomes for their patients.

Adding SDOH to the clinician workflow

When a health care provider has acquired the data and analytics capabilities that yield patient-level SDOH information, how do they add it to the workflow in a way that will benefit clinicians and the care team – and the patient – the most? The data should empower clinicians to ask the right questions and give the best instruction and referrals when those things are most needed.

While we are in the early stages of applying SDOH to EHR and population health management applications, the requirements are clear. Capabilities should include:

• Making a patient’s SDOH information visible to caregivers at the point of care.
• Allowing providers to develop a social care plan that's integrated with the clinical care plan.
• Assigning tasks. For each task in the care plan, there must be a mechanism to assign it to the appropriate care team member.
• Automatically linking to resources to address the needs flagged in the social plan.
• Supporting patient interaction with social services. Patients should be provided resources that help them find and use social services.

All these IT capabilities rest on a foundation of partnerships between health care providers and social services organizations.

Health care provider and social services partnerships

One of the more challenging aspects of wrapping SDOH into a care plan is figuring out who can best help solve a given social problem. Some providers with large Medicaid and uninsured populations have long addressed SDOH in their communities and have developed some of their own resources, but most will have to reach out to community organizations and social service agencies, whose budgets and fortunes may rise and fall unpredictably and whose staffs are often in flux.

The IT department may not be given the responsibility for developing these partnerships, but it might be asked to devise methods of maintaining an up-to-date database and will almost certainly be asked to integrate referral tools into the workflow. Several efforts, both commercial and nonprofit, have sprung up to fill these needs. They vary in their specific services and their completeness, and keeping current is always a challenge.

No single source is likely to fulfill all of a given provider’s requirements, but here are a few that can help organizations get started:

• 211: A service of the United Way that rounds up links for all “211” health and human services referral services in the U.S. and Canada.
• Aunt Bertha: A for-profit organization that claims links to hundreds of programs serving every U.S. ZIP code. Basic use is free, with advanced collaboration features available at various price points.
• Healthify: A for-profit offering database, EHR integration, assessment tool and analytics.
• Health Leads: A nonprofit offering tools, training and resources for integrating SDOH into accountable care.
• NowPow: A for-profit offering curated resource lists and patient engagement tools.
• TavHealth: A for-profit offering database, collaboration tools, analytics and community resources management services.

Integrating IT in the community

As health care providers implement IT support of SDOH, they will need to interact with the IT capabilities of a potentially wide range of social services organizations. These organizations will vary wildly in their level of IT experience, expertise, existing systems and budget resources.

At a minimum, the provider’s care team and the community agencies should be able to send and receive secure messages, and those messages should integrate into the patient’s EHR and population health management systems so that everyone can keep track of the social care plan in much the same way as specialists close the loop with primary care providers. Social service agencies, community health workers or others may need at least partial access to EHR and population health management information to track the patient’s progress or respond to flagged needs. In cases where collaborating agencies have appropriate IT, providers may be able to use communication standards like SMART on FHIR to provide useful integration.

Worth exploring in some situations: extending the capabilities of health system IT into the community organizations that are most involved in addressing patients’ SDOH issues. Some providers have been through a version of this process when extending EHR access to physician practices in their communities. In conjunction with that effort, the U.S. Department of Health & Human Services extended the “safe harbor” rule for EHR donations until 2021. While the two situations aren’t exactly parallel and providers will want to consult their attorneys on legal and regulatory aspects, many providers are uniquely positioned to offer some social service providers a badly needed IT boost that can also solidify community partnerships.

Innovating for social health

Addressing a patient’s SDOH factors will enable us to take significant leaps forward in improving the health and health care of patients and communities. The evolving integration of medical care and social care is already leading to impressive innovations by care providers. These innovations will be able to make significant advances as we extend the IT capabilities to deliver robust and full-function SDOH support.

Here are a few current innovations that we find promising:

• New York’s Mount Sinai Health System recently launched a partnership with several legal aid services to address legal issues that can be barriers to good health and optimal care. The attorneys will help with trust and estate planning (for terminally ill patients), changing names and stated gender on legal documents (for transgender patients), and legal services for at-risk children and youth in their interactions with the educational system and the criminal justice system.
• Geisinger Health System offers “Fresh Food Pharmacy,” a program that helps food insecure diabetic patients get free groceries and meal plans that help keep their disease under control by giving them food “prescriptions,” along with monitoring and coaching.
• Carolinas Healthcare and Novant Health, normally competitors in North Carolina, are working together using data from Quality of Life Explorer, an SDOH mapping application developed through a collaboration of several organizations and public agencies. Among other projects, they will coordinate on where to put new primary care clinics, identify food deserts and address high rates of diabetes in certain neighborhoods of the communities they both serve.

With the amount of energy and imagination in our industry, we know that these few examples are just a taste of what is to come. We have not yet even begun to see the full range of ways that addressing SDOH can improve community health.

At Cerner, we're focused on connecting traditional venues, the health continuum and advanced information about a person's lifestyle to empower individuals in their health and care.