Healthcare organizations looking to cut costs and improve patient care are increasingly exploring how the conditions in which people live and work contribute to long-term outcomes.

Research now indicates that the social determinants of health (SDOHs), such as housing stability, access to transportation, and psycho-social safety, have an outsized impact on a patient’s ability to engage with the healthcare system and follow treatment plans for chronic and acute conditions.

Yet healthcare systems are still struggling to understand their patients’ challenges and how to connect individuals with the support they need.

In a 2017 benchmark survey by Deloitte, researchers found that 88% of hospitals have processes in place screen their patients for SDOHs, but only 62% do so consistently and systematically.

And while hospitals and health systems are investing millions of dollars in their communities to improve housing stability and healthcare access, almost 40% of organizations admitted that they have no ability to measure the outcomes of these activities.

Part of the problem is the difficulty of collecting standardized data about social determinants and analyzing this data in a way that provides actionable insights to front-line providers at the point of care.

How can healthcare providers collect and leverage social determinants data more effectively to produce positive outcomes for patients?

Have the tough conversations

Talking about sensitive issues such as financial security, lifestyle choices, and family dynamics can be difficult for both patients and providers, especially when appointments last only a few minutes.  Providers need to make an extra effort to collect data about SDOHs to ensure their clinical interventions are truly effective once the patient returns to his or her community setting.

Surveys and questionnaires can help to guide these conversations, establish strong relationships, and create trustworthy data assets that can be used for larger-scale analysis.  Health system leaders may wish to offer their staff additional training on motivational interviewing and empathetic listening to encourage more open communication between patients and their clinicians.

Utilize Z codes for standardizing SDOH data collection

Z codes are a subset of the ICD-10-CM code set.  They are specifically designed to capture information about social determinants of health and provide almost 100 different ways to record a wide variety of high-impact socioeconomic factors in a standardized manner.

However, these codes are sorely underutilized.  A new report from CMS finds that only 1.4 percent of Medicare patients in 2017 had claims that included Z codes, representing less than 500,000 individuals out of 33.7 million Medicare fee-for-service beneficiaries.

Increasing the use of these standard codes could help healthcare providers better understand the needs of their populations and target their limited resources accordingly.

Connect with community groups and social service agencies

Federal agencies, state-level organizations, and local charitable social services groups often provide a great deal of support for individuals struggling with socioeconomic challenges.

Healthcare organizations should collaborate as closely as possible with community resources to ensure patients receive referrals to appropriate programs, such as emergency housing initiatives, food banks, job training, and home care options.

Tools such as the Community Preventive Services Task Force’s Community Guide and The Social Care Network, a national directory of free or low-cost SDOH services, can help providers refer individuals to available resources within their communities.

Providers also need to make sure they are closing the feedback loop when individuals do receive services. Using standardized questionnaires to identify needs and recording those needs with Z codes can make it easier for providers to cross issues off the list when they have been addressed or follow up on problems that have fallen through the cracks.

Leverage analytics to stay ahead of community challenges

Population health analytics is one of the fastest growing health IT markets for a reason.  Predicted to reach $150.6 billion by 2027, the population health analytics segment includes tools and technologies that help providers stay ahead of SDOHs and their associated clinical manifestations.

Understanding patterns in clinical risk scores, avoidable ED utilization, preventable readmissions, and chronic disease burdens can give providers invaluable insight into how to best serve their communities.

Providers should look for a population health tool that aggregates from multiple areas of the organization, offers dashboards and custom reporting to connect key stakeholders with relevant insights, and assists with closing gaps in clinical care and socioeconomic need.

Develop and deploy measures to monitor progress

The final step in a more data-driven approach to identifying and addressing SDOHs is measuring progress and reporting on opportunities to improve.

Healthcare organizations will need to measure and manage multiple indicators of success, including improved clinical outcomes, physician-level performance on relevant aspects of care, and spending on key services.

Creating trusted, shared measures of performance across a health system will allow for a more reliable barometer for success and motivate individual stakeholders to implement necessary improvements.

For providers participating in value-based care arrangements, the ability to closely monitor the clinical and financial outcomes of population health management initiatives is particularly important, since these metrics are directly tied to incentives or penalties.

Successfully addressing the social determinants of health for vulnerable populations requires a structured foundation of analytics tools as well as a strong human element: the ability to have difficult conversations and connect individuals with the help they need in a compassionate, respectful, organized way.

By combining data analytics with a systematic approach to community collaboration, healthcare organizations can support better health for their patients at the clinic, at home, and everywhere in between.

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