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What population health IT vendors are doing to support SDOH continued.......

By Bill Siwicki


Structured SDOH data capture


At the patient level, Enli Health enables structured SDOH data capture through its CareManager care plan dashboard that is embedded in the EHR or accessible in a web page, said Siemienczuk.


“Enli leverages the CPC+ SDOH assessment, and additionally allows configurable mapping for PRAPARE and other common SDOH assessment types,” he explained. “The assessment logic assigns a risk status, which is surfaced in the care plan dashboard to aid decision making, and also used to drive workflows in Enli’s care coordination application, Central Worklist.”

At the population level, the Care Manager social determinants module allows users to risk stratify on specific SDOH measures and overdue assessments. Cohorts can be exported to out-of-the-box or customizable workflow programs in the Central Worklist care coordination application. Integrated reporting capabilities include CPC+ and LOINC code push, he added.


Using the SDOH data

Each of the vendors’ pop health IT has similar outcomes for users incorporating SDOH data. Users see and use a variety of data.

“We have reimagined population health IT to fundamentally incorporate social determinants, opening up our context to account for the delivery of all care, not just medical care,” said Jones of GSI Health. “Our technology can help you identify and separate socially complex populations from medically complex, and enable an orchestration of care around prescribed workflows to address all issues including social determinants of health.”



"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."

LeRoy Jones, GSI Health

This ensures that each care team member has what they need to treat the right people at the right time with the right actions, improving how they deliver care to these challenged populations, he added.

“All users of our technology, including social service providers, are full-fledged teammates and able to contribute the benefit of their expertise,” he continued. “Each team member sees what is germane to them, organized in a way that is relevant, instead of being forced into a different paradigm such as a medical record and having to dig through notes to find the information they need.”

The entire care team has transparency into what is being done by each organization to mitigate these issues, and how successful each strategy is, he said. The technology can be configured for the specific social determinants that are important to a population so that one can identify the right socially complex cohorts that need additional support and enroll them into the right programs according to the organization’s business model, he said.

This ensures that each care team member has what they need to treat the right people at the right time with the right actions, improving how they deliver care to these challenged populations, he added.


“All users of our technology, including social service providers, are full-fledged teammates and able to contribute the benefit of their expertise,” he continued. “Each team member sees what is germane to them, organized in a way that is relevant, instead of being forced into a different paradigm such as a medical record and having to dig through notes to find the information they need.”

The entire care team has transparency into what is being done by each organization to mitigate these issues, and how successful each strategy is, he said. The technology can be configured for the specific social determinants that are important to a population so that one can identify the right socially complex cohorts that need additional support and enroll them into the right programs according to the organization’s business model, he said.

To help you improve your model of care, our technology includes reporting and dashboards that are organized around social determinants of health, enabling you to identify what social issues impact utilization and cost the most across all your partners and the system as a whole,” Jones explained.

“For example, we offer a care management outcomes dashboard that enables clients to understand housing security for their population, highlighting issues such as the percent that are homeless, how long they have been homeless, and more.”

As a result, providers are able to use the technology to evaluate both processes and outcomes so they can tune their activities to make them more effective, he added. By optimizing the work, the outcomes will be better, he contended.


Right in the workflow

Providers will be able to see social determinants of health data for individual patients and populations directly in the workflow, said Gupta of Cerner.

“By having this data incorporated, providers are supported with a fuller picture of a person’s overall health, including outside factors that may affect their ability to get better and stay healthy,” he said.

“Providers can use this to tailor how they handle care for each patient,” he added. “For patients whose conditions are similar on paper, providers can use social determinants of health to see if certain patients may need additional help or intervention to increase compliance with treatment plans.”

Cerner’s SDOH-oriented technology is designed to help healthcare organizations manage problems related to health, not just disease, Gupta said.

“Providers can now also refer patients to a wide variety of social service providers through the HealtheIntent platform in order to help patients have both their medical and social determinant needs addressed,” he said.

At the patient level, overdue SDOH assessments and high-risk areas are surfaced to providers through the Care Manager care plan dashboard, said Siemienczuk of Enli Health Intelligence.


“Ensuring up-to-date assessments is a measure of some commercial and governmental reimbursement programs,” he explained. “Presenting information on social risks can enable staff and providers to address priority needs during a patient encounter.”

At the population level, the Care Manager social determinants module enables filtering on risk and assessment status. SDOH factors can be combined with clinical risk factors to better target and individualize interventions. Identified priority cohorts can be automatically exported to a Central Worklist care coordination workflow that orchestrates tasks and actions among members of the core and extended care team.


The results of having electronic SDOH data

Vendors’ population health IT that incorporates SDOH data directly affects patient care. Having SDOH data in an electronic format is meaningful to caregivers.

Many of the more forward-looking healthcare organizations are attempting to increase their involvement with social influences inside the geographical area they may primarily operate. For hospitals and health systems, that means bringing in more people with varying areas of expertise.

“Providers are using social determinants of health data to execute on public health initiatives that they haven’t traditionally considered,” said Gupta of Cerner. “Some healthcare organizations are expanding the care team to not only include the physician but also care managers, social workers, family members and even medical legal aids who can work on behalf of patients that need some assistance.”

SDOH data adds pragmatism to a patient’s personalized care pathway by incorporating the non-medical factors that impact health outcomes, said Siemienczuk of Enli Health Intelligence. Information provided on the local food bank and assignment of a caseworker to assist with housing placement are examples of possible uses, he added.


The whole-person care approach

A whole-person care approach that leverages SDOH data in electronic format helps care teams identify non-medical issues that impact the patient and work on those issues alongside medical care so that the patient receives more comprehensive care.

Our platform enables care teams to identify issues and implement client-configured, standardized interventions that connects patients to the right type of care,” said Jones of GSI Health. “This enables providers to function at the top of their licenses, eliminating overlap and ensuring that each member of the integrated team does what they are trained to do.”

Prescriptive programs, workflows and guidelines ensure that everybody is working together rather than implementing divergent protocols within their silos, he added.

“The trick is how to figure out if those efforts were successful,” he explained. “You can’t fix what you can’t measure, and you can’t measure if you can’t capture data in a consistent way. One of the values our technology brings is the ability to standardize the representation of those SDOH factors through consistent assessments and data elements.”

This enables a new generation of analytics that helps one understand the impact of social determinants on an entire population so that one can proactively address SDOH, he said.


How social issues impact cost and outcomes

“For example, Care Compass Network in New York uses our technology to capture social determinants of health information, and shares it with another system to adjust risk scores,” Jones noted. “By calling out the issues facing socially complex populations, you can drill down to how those social issues impact cost and outcomes, rather than analyzing the issues as part of a broader population. This capability is fundamental to improving the circumstances of more challenged populations.”


GSI Health clients are achieving results by addressing social determinants: While each organization measures success differently, the technology has empowered clients to work more efficiently and effectively to reduce readmissions and the total cost of care, reduce emergency department usage as the first point of entry, increase the use of primary care, improve connectivity to services that address social determinants, and improve transitional care for more vulnerable populations, Jones said.


“One example of the success of this approach is how Pathway Home, a Care Transition Program of Coordinated Behavioral Care in New York, successfully transitioned patients to function in the community through a program focusing on patient support systems and community ties during the critical period following discharge,” he said. “A key result is that 94% of their participants stayed out of the hospital during their first 30 days back in the community, compared with an 87% psychiatric hospitalization readmission rate in those same 30 days.”


https://www.healthcareitnews.com/news/what-population-health-it-vendors-are-doing-support-sdoh


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