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Social determinants of health data provide better care

Knowing the use cases for social determinants of health, such as coordinating care and identifying care gaps, is an important first step in making the data worthwhile.

Social determinants of health data can help healthcare organizations deliver better patient care, but the challenge of knowing exactly how to use the data persists.

The healthcare community has long-recognized the importance of a patient's social and economic data, said Josh Schoeller, senior vice president and general manager of LexisNexis Health Care at LexisNexis Risk Solutions. The current shift to value-based care models, which are ruled by quality rather than quantity of care, has put a spotlight on this kind of data, according to Schoeller.

But social determinants of health also pose a challenge to healthcare organizations. Figuring out how to use the data in meaningful ways can be daunting, as healthcare organizations are already overwhelmed by loads of data.

A new framework, released last month, by the not-for-profit eHealth Initiative Foundation, could help. The framework was developed by stakeholders, including LexisNexis Health Care, to give healthcare organizations guidance on how to use social determinants of health data ethically and securely.

Here's a closer look at the framework.

Use cases for social determinants of health data

The push to include social determinants of health data into the care process is "imperative," according to eHealth Initiative's framework. Doing so can uncover potential risk factors, as well as gaps in care.

Examples of social determinants of health

  1. Access to educational, economic and job opportunities
  2. Availability of community-based resources
  3. Transportation options
  4. Public safety
  5. Social support

Source: U.S. Department of Health and Human Services, Healthy People 2020

The eHealth Initiative's framework outlines five guiding principles for using social determinants of health data. 

  1. Coordinating care

Determine if a patient has access to transportation or is food is insecure, according to the document. The data can also help a healthcare organization coordinate with community health workers and other organizations to craft individualized care plans.

  1. Using analytics to uncover health and wellness risks

Use social determinants of health data to predict a patient's future health outcomes. Analyzing social and economic data can help the provider know if an individual is at an increased risk of having a negative health outcome, such as hospital re-admittance. The risk score can be used to coordinate a plan of action.

  1. Mapping community resources and identifying gaps

Use social determinants of health data to determine what local community resources exist to serve the patient populations, as well as what resources are lacking.

  1. Assessing service and impact

Monitor care plans or other actions taken using social determinants of health data and how it correlates to health outcomes. Tracking results can help an organization adjust interventions, if necessary.

  1. Customizing health services and interventions

Inform patients about how social determinants of health data are being used. Healthcare organizations can educate patients on available resources and agree on next steps to take.

Getting started: A how-to for healthcare organizations

The eHealth Initiative is not alone in its attempt to move the social determinants of health data needle.

Niki Buchanan, general manager of population health at Philips Healthcare, has some advice of her own.

  1. Lean on the community health assessment

Buchanan said most healthcare organizations conduct a community health assessment internally, which provides data such as demographics and transportation needs, and identifies at-risk patients. Having that data available and knowing whether patients are willing or able to take advantage of community resources outside of the doctor's office is critical, she said.

Look for things that meet not only your own internal ROI in caring for your patients, but that also add value and patient engagement opportunities to those you're trying to serve in a more proactive way.
Niki BuchananGeneral manager of population health management, Philips Healthcare
  1. Connect the community resource dots

Buchanan said a healthcare organization should be aware of what community resources are available to them, whether it's a community driving service or a local church outreach program. The organization should also assess at what level it is willing to partner with outside resources to care for patients.

"Are you willing to partner with the Ubers of the world, the Lyfts of the world, to pick up patients proactively and make sure they make it to their appointment on time and get them home," she said. "Are you able to work within the local chamber of commerce to make sure that any time there's a food market or a fresh produce kind of event within the community, can you make sure the patients you serve have access?"

  1. Start simple

Buchanan said healthcare organizations should approach social determinants of health data with the patient in mind. She recommended healthcare organizations start small with focused groups of patients, such as diabetics or those with other chronic conditions, but that they also ensure the investment is a worthwhile one.

"Look for things that meet not only your own internal ROI in caring for your patients, but that also add value and patient engagement opportunities to those you're trying to serve in a more proactive way," she said.

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