As value-based care contracting grows, health systems are increasingly seeking to impact the social determinants of health (SDOH), such as social issues, individual behavior, and environmental elements. Given that SDOH affect patients more than healthcare does, addressing them is key to an effective population health management strategy.
Identify Key Factors. Using evidence-based assessments to screen all patients for behavioral health needs, financial and housing concerns, violence and trauma issues, and other topics is considered a population health best practice. This data gives health systems a deeper understanding of the issues affecting their patients. ECG used this strategy with a large medical group to identify depression and connected social issues such as isolation among patients. By screening all patients, condition-specific heat maps could be generated. Some health systems have supplemented their own internal data with community health assessments performed in their service areas, which positioned them to affect their current patient population and be leaders in their communities.
Develop Measurable Strategies. Once data has been analyzed, a strategy to impact the determinants needs to be developed. These strategies need to include how the effects will be measured. Some payors that have identified beneficiaries with food insecurities connected these beneficiaries to food banks and nutritional assistance programs for which they qualify. These payors are broadly tracking the resource usage and health indicators of these beneficiaries to understand how decreasing food insecurity affects health outcomes. Process and outcome measures paint a full picture of the return on investment.
Socialize Successes and Challenges. Most social determinants happen outside of health system walls; sharing the results of these SDOH strategies with patients and the community demonstrates a commitment to total patient health. Internally, we have worked with health systems that are using social media to share these stories. At a community level, we have seen a children’s hospital be a leader in a statewide discussion on suicide and improving pediatric mental health coordination. Connecting health system efforts to address SDOH in the community will result in a stronger reputation and partnerships that benefit patients in the long term.
Previously appeared in the May 2018 issue of Population Health News