Andy Aroditis

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The COVID-19 pandemic is not just a medical crisis.Since the highly contagious disease hit American shores in early 2020, the virus has dramatically changed all sectors of society, negatively impacting everything from food supply chains and sporting events to the nation’s mental and behavioral health.

For some people, work-from-home plans and limited access to entertainments are manageable obstacles.For others, the shuttered schools, lost wages, and social isolation spell disaster – especially for individuals already living with socioeconomic challenges.

The social determinants of health have always been important for understanding why some populations are more susceptible to increased rates of chronic conditions, reduced healthcare access, and shorter lifespans.COVID-19 is throwing the issue into high relief.

Now more than ever, healthcare providers need to gain full visibility into their populations and the non-clinical challenges they face in order to help individuals maintain their health and keep their communities as safe as possible during the ongoing pandemic.

Exploring correlations between socioeconomic circumstances and COVID-19 vulnerability

Clinicians and researchers have worked quickly to identify patterns in the spread of COVID-19.Early results have 

 the danger posed by advanced age and preexisting chronic conditions such as obesity, diabetes and heart disease.

Further, data from the Johns Hopkins University and American Community Survey 

 that the infection rate in predominantly Black counties is three times higher than in mostly white counties. The death rate is six-fold higher.

 from CMS confirms what Johns Hopkins reported: Black Medicare beneficiaries are hospitalized at a rate of 465 per 100,000 compared to just 123 per 100,000 white beneficiaries. Hispanic Medicare beneficiaries had 258 hospitalizations per 100,000, more than double the white population’s hospitalization rate.

Researchers suggest that the social determinants of health may be largely responsible for these disconnects in infection and mortality rates.Racial, ethnic, and economic factors are strongly correlated with increased health concerns, including longstanding disparities in access to care, higher rates of underlying chronic conditions, and differences in health literacy and patient education.

Leveraging data-driven tools to identify vulnerable patients

Healthcare providers will need to take a proactive role in identifying which of their patients may be at enhanced risk of contracting the virus and experiencing worse outcomes from the disease.

They will also need to ensure that person gets adequate treatment and participate in contact tracing efforts after a positive test.Lastly, providers will have to ensure their public health reporting data is accurate to inform local and regional efforts to contain the disease.

The process begins by developing confidence in the identity of each individual under the provider’s care.Healthcare organizations often struggle with unifying multiple electronic health record (EHR) systems and other health IT infrastructure, resulting in medical records that are incomplete, inaccurately duplicated, or incorrectly merged.

Access to current and complete medical histories is key for highlighting at-risk patients.An enterprise master patient index (EMPI) can provide the underlying technical foundation for initiating this type of population health management.

EMPIs help organizations create and manage reliable unique patient identifiers to ensure that records are always associated with the correct individual as they move throughout the healthcare system.

When paired with claims data feeds, health information exchange (HIE) results, and interoperability connections with other healthcare partners, EMPIs can bring a patient’s complete healthcare status into focus.

This approach ensures that providers stay informed about past and present clinical issues and service utilization rates.It can also support a deeper dive into the social determinants of health.

Combining EHR data with standardized data about socioeconomic needs can help providers develop more comprehensive and detailed portraits about their patients’ holistic health status.

By including this information in EHRs and population health management tools, providers can develop condition-specific registries to guide outreach activities. Providers can deploy improved care management strategies, close gaps in care, and connect individuals with the resources they need to stay healthy.

Healthcare organizations can acquire socioeconomic data about their communities in a variety of ways, including integrating 

 into their population health management tools and collecting individualized data using 

Once providers start to understand their patients’ non-clinical challenges, including the ability to avoid situations that may expose them to COVID-19, they can begin to prioritize patients for outreach and develop personalized care plans.

Conducting effective outreach and interventions for high-needs patients

COVID-19 has taken a staggering economic toll on many families, including those who may have been financially secure before the pandemic. Routine healthcare, prescription medications, and even some urgent healthcare needs are often the first to fall by the wayside when finances get tight.

Healthcare providers have gotten creative about staying connected to patients through telehealth, drive-in consults, and other contactless strategies.But they must also ensure that their vulnerable patients are aware of these options – and that they are taking advantage of them.

Contacting a large number of patients can be challenging since phone numbers, emails, and home addresses change frequently and are prone to data entry errors during intake. Organizations with EMPIs can leverage their tools to ensure contact information is up to date, accurate, and associated with the correct individual.

Care managers should prioritize outreach to patients with complex medical histories and known clinical risks for vulnerability to COVID-19.These conversations are a prime opportunity to collect social determinants of health information or refresh existing data profiles.

Looking to the future of healthcare in a COVID-19 world

Combining technology-driven strategies with targeted outreach will be essential for healthcare organizations aiming to provide holistic support for their populations during – and after – the COVID-19 pandemic.

By developing certainty about patient identities and synthesizing that information with data about the social determinants of health, providers can efficiently and effectively connect with their patients to offer much-needed resources.

Taking a proactive approach to addressing the social determinants of health during the outbreak will help providers maintain relationships with high-needs patients while building new connections with those facing unanticipated challenges.

With a combination of population health management strategies and innovative technology tools, healthcare providers and public health officials can begin to view the social determinants of health as a fundamental component of the fight against COVID-19.

, the global leader in healthcare enterprise identification.

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COVID-19 has revealed the importance of the social determinants of health.

Accounting for the Social Determinants of Health During the COVID-19 Pandemic

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.

, a global leader in healthcare enterprise identification.

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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Accounting for the Social Determinants of Health During the COVID-19 Pandemic

Why Addressing SDOH Starts with Patient Matching