Three representative vendors discuss why social determinants of health are important to population health management, and describe how their technologies help put these important data points to work.
By Bill Siwicki September 05, 2019 01:34 PM
Social determinants of health have proven and measurable impacts on the health outcomes of patient populations. This is why the healthcare industry is seeing heightened focus on SDOH from many sectors, including payer organizations, health systems and independent medical groups.
SDOH are factors influencing patient outcomes that are outside the scope of traditional medicine. These might include geographical factors such as where a patient lives, social factors like interpersonal relationships, cultural factors like religion and economic factors such as income.
Different from SDOH, and more foundational to patient health and well-being, are critical needs, such as water, food, shelter and clothing.
Value-based care on the rise
“From a population health management perspective, priority cohorts are traditionally identified based on clinical factors,” said Dr. Joseph Siemienczuk, chief medical officer at Enli Health Intelligence, a population health IT vendor.
“As value-based reimbursement increases in prevalence, health systems are inclined to better understand all attributed patients, including their social barriers that could impact health,” he said. “The case to incorporate SDOH into population health management becomes an equation of downside risk versus the cost of health investment.”
Understanding social barriers to health improvement and operationalizing those insights into the clinical workflow can better individualize a patient’s care pathway, which leads to better financial and population health outcomes, he added.
Environmental and social factors can have a major impact on a person’s health, said Dr. Tanuj Gupta, senior director and physician executive at Cerner.
“If a person doesn’t have to worry about where their next meal is coming from, they may have more time and energy to focus on nutrition,” he explained. “If a person has a car and health insurance, they may be more likely to see a doctor regularly to maintain good health.”
Populations that do not have access to nutritious food, reliable transportation, safe housing or health insurance are at a higher risk for health issues. Using social determinants of health – the conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes – is about preventing people from getting sick and optimizing positive outcomes when they are sick.
Hierarchy of needs
When it comes to population health, it’s not enough to just understand the medical issues that affect a patient – one must consider the whole person, contended LeRoy Jones, founder and CEO of GSI Health, a population health IT vendor.
“People tend to rationalize social determinants of health first in their hierarchy of needs, so if people are worried about where they’re going to sleep, they aren’t thinking about taking the right medications or going to an appointment,” he stated. “Sometimes you have to treat the most acute pain the patient is experiencing – even if the pain is a social determinant – before the treatment for a medical condition can be effective.”
"Through this non-clinical referral resource platform, care managers are able to understand at-risk populations and connect individuals to resources in the community to address social vulnerabilities."
Dr. Tanuj Gupta, Cerner
Medical care accounts for only 10-20% of the modifiable contributors to health outcomes, so addressing the remaining 80%, i.e. the behavioral and social determinants that negatively impact health, is where actions can really make a difference, he added.
“These social determinants are true impediments to health, with many variables that can be tuned to improve not only how you impact an individual’s well-being, but how you systematically improve the health of an entire population,” he explained. “This is especially true for challenged populations that are costly to manage.”
Because these factors are such a big part of the lives of these challenged populations, healthcare organizations cannot effectively treat them without treating social determinants in a real way alongside medical treatment, he said.
Being able to address real issues that undermine quality medical care and unequivocally have an impact on population health is why this new era of social determinants of health is so exciting, he said.
What vendors’ systems do with SDOH
It’s clear social determinants are important to the future of effective population health management. So what are population health IT vendors doing today to ensure their technologies incorporate and deploy SDOH data?
“Cerner has developed screening tools for providers to collect social determinants of health data,” said Gupta of Cerner. “Screening tools can be self-administered in a portal or via a clinical or non-clinical staff member in the EHR. The clinician can use the tools and the data they collect to better communicate with the patient and work to resolve issues like food insecurity, transportation, housing and other social determinants of health.”
The Cerner population health platform, HealtheIntent, is able to collect and analyze client data, including social determinants of health information, to help healthcare organizations know and predict what will happen within their populations and engage the person to take action.
“Cerner also has enabled social service directory services to integrate with our platform in order to provide ways for health systems to broaden their options for referrals to social service providers,” Gupta explained. “Through this non-clinical referral resource platform, care managers are able to understand at-risk populations and connect individuals to resources in the community to address social vulnerabilities.”
This can include resources and offerings such as housing, transportation, financial support, meals and more. Care managers are able to track patients and ensure they are receiving the support that has been provided to them.
SDOH are fundamental to patient care
GSI Health believes the idea of extending care to treat the whole person by enabling social determinants to be a full part of a patient’s care is not just additive to medical care but fundamental, said Jones.
“Therefore, addressing social determinants is ubiquitous in all we do – in how we bring together medical, behavioral and social service providers across the community to collaborate as teams with integrated workflows, include behavioral and social determinants in the care plan, collect and report on data, and integrate and share information across organizations,” he said.
"As value-based reimbursement increases in prevalence, health systems are inclined to better understand all attributed patients, including their social barriers that could impact health."
Dr. Joseph Siemienczuk, Enli Health Intelligence
The GSI Health platform is designed not just for one organization to use, but to bring community-based organizations that address social determinants onto a shared platform with the medical team to collaborate with transparency across the team.
“Our technology expands the traditional scope of care coordination by enabling the types of users that address SDOH to work shoulder-to-shoulder with medical providers as full-fledged care team members, using tools that are appropriate for the work they do and sharing information on what happens when the patient leaves the medical facility,” Jones said.
The platform enables collaborative workflows across diverse settings, with configurable program-specific actions to drive care management consistently across organizations so that the social determinant work being performed is transparent across the team and all team members have the up-to-the-minute information they need to be effective, he added.
“Our care management platform also provides insight into how your care management processes influence your results so that you know which activities have the most impact on your population,” he explained. “We look beyond traditional data sources like EHRs and claims and analyze care management activities that impact care, cost, quality and utilization.”
Integrating and analyzing information across all community-based partners provides insights into how processes are working and how behavioral health and social determinants impact a population and the bottom line so one can understand what’s moving the needle and tune one’s activities to improve one’s outcomes, Jones said.
To be continued........
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