Andy Aroditis

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Addressing social determinants of health (SDOH) is a critical industry issue as population health and the pursuit toward value continue to unfold. Because the health of an individual is heavily influenced by socioeconomic and behavioral forces, access to a complete picture of one’s health is key to better care coordination, improved quality and safety, and greater patient and provider satisfaction.

Social factors are considered to be so impactful because 

only about 20% of health outcomes are determined by clinical care

. The remaining 80% is determined by non-clinical factors, most of which are influenced by geography and socioeconomic conditions. This explains why communities with poor overall health status can actually overshadow a thriving health care system that surrounds it.

As such, healthcare executives are increasingly looking for tools that extend out into non-clinical or traditional settings to assemble a longitudinal view of the patient. Progressive healthcare executives-tired of EHR systems that only provide a limited assessment of one’s needs-are leveraging patient matching technology as a strategic advantage to integrate SDOH data more quickly and efficiency.

Patient identification tools for many institutions are rapidly transforming from a line of defense against duplicate medical records to the default approach for interoperability and connectivity across diverse systems and locations. Since social determinants make up the majority of factors contributing to population health, building a total picture of an individual to offer intervention and support will require accurate patient identification and cross-system interoperability outside the hospital’s four walls.

Complementing extensive clinical data with SDOH will allow care managers to make more informed decisions and apply data-rich insights into a patient’s treatment plan.

Deploying analytics tools to social needs data is showing signs of promise, particularly as organizations seek to reduce the likelihood of readmissions. When screening for social needs is combined with medical records, this critical data can be more readily collected, stored, accessed, and put to use across many settings and locations.

Tools that offer reliable patient ID matching and medical record management facilitate the ability to track individuals uniquely across a diverse set of systems and facilities. This enables a clear and holistic view of a given patient and promotes a more consistent patient experience. This important step in meeting social needs gives providers the opportunity to find potential gaps in care by seeing the entirety of a patient’s medical history.

Incorporating SDOH data into electronic medical records with use of patient matching technology can help organizations identify at-risk individuals and reduce readmissions among its vulnerable populations.

 found social determinants of health contributed to more than 50% of hospital readmissions. By tracking individuals across disparate clinics and public health agencies, health IT leaders can leverage such data as reading level and water purity into their care services.

Exerting control over social determinants isn’t the end goal of providers, but to offer interventions outside of clinical care to improve value-based, population health. Screening and intervention are logical steps in assessing social determinants but knowing how to effectively collect, track and manage this data will be critical.

So far, solutions have been mainly focused on intervention and engagement with limited to moderate success and no guarantee of a return on investment. Until more innovative solutions or partnership opportunities emerge, reliable patient matching and interoperability tools will be an imperative foundation to painting a more complete picture of an individual and offering insight into their ability to benefit from specific care plans.

With a greater understanding of the significant impact of social determinants, providers can begin to implement tools and strategies that incorporate these factors for better patient engagement and outcomes, reduced cost and duplication of services, and enhanced clinical decision-making and coordination of care.

4 Ways Health Plans and Communities Can Address SDOH

Gaining access to complete and accurate patient data that flows freely across boundaries will be catalyst for improving community health and well-being, as well as a key factor in helping individuals overcome the socioeconomic barriers that place their health at risk.

By building social needs into the patient data capture process, providers can track individuals across the care continuum, thereby improving the likelihood of care plan success and prospering in an era of increased accountability.

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The first step to tackling one of healthcare’s biggest problems is to gain more complete access to patient data.

Author | Andy Aroditis

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