In my years as a healthcare provider, I've seen how the conditions in which people live, work and seek care shape their health in profound ways. Whether it's a rural community grappling with limited resources or an urban patient facing housing insecurity, these social factors often dictate health outcomes. But the tide is shifting. Technology is stepping in to help level the playing field, enabling care teams to identify and address these critical determinants.
Addressing the Complex Care Continuum
One of the biggest challenges in both acute and post-acute settings is the complexity and inefficiency of the care continuum. Transitions between hospitals, emergency departments (ED), and post-acute care facilities are often disjointed, leading to delays and poor health outcomes for patients. ED overcrowding remains a significant issue, with many patients seeking help for non-emergency needs, which clogs the system and slows down care for those who need it most. In the U.S. alone, 90% of EDs were regularly reporting overcrowding before the COVID-19 pandemic hit.
Data sharing allows care teams to proactively address issues like housing insecurity, food scarcity, and behavioral health crises — factors that often lead to unnecessary ED visits. By surfacing critical insights, such as high ED utilization or recent discharge history, clinicians can prioritize patients facing SDOH barriers. And with the right information at our fingertips, we can make decisions that truly benefit the patient rather than simply reacting to immediate symptoms.
As an emergency medicine physician, I've seen firsthand how the lack of data can lead to unnecessary treatments and missed opportunities for timely intervention. Technology is changing that. Through enhanced connectivity and insights, we now have a more complete picture of a patient's health, addressing the social factors that often drive patients to the ED.
The Power of Data-Driven Insights
Patient data is a game-changer in optimizing ED outcomes and addressing SDOH. High ED utilization—such as five or more visits within 12 months—can indicate a patient is struggling with social determinants like housing insecurity or behavioral health crises. Similarly, rising-risk patients who visit multiple EDs within a short timeframe require targeted intervention.
Through these insights, ED staff can gain "at-a-glance" visibility into key factors such as ED care guidelines, recent security events, sepsis history, or patients at risk of readmission. These insights are instrumental in guiding care decisions, particularly when it comes to addressing behavioral health events, substance use disorders, and even mental health diagnoses like suicidal ideation.
Interoperability is key to this process. By connecting the dots between a patient's medical history, their social conditions, and their current healthcare needs, we can deliver more efficient, effective care that addresses the whole person.
Enhancing Outcomes through Regional Partnerships
Collaboration between healthcare organizations across urban and rural settings is also essential to improving outcomes. Data sharing between these organizations can level the playing field, ensuring that patients in underserved areas receive the same quality of care as those in more resource-rich urban centers.
For example, partnerships that address behavioral health crises or maternal health issues can significantly improve care delivery by giving clinicians the insights they need to intervene early. These collaborations, supported by robust health technology, ensure that even the most vulnerable populations receive timely, appropriate care.
Realizing the Benefits of Addressing SDOH
The benefits of addressing SDOH go beyond reducing hospitalizations or readmissions; it's about ensuring that patients receive the care they truly need when they need it.
Value-based care models play a critical role in incentivizing this approach. As we transition to value-based care, more organizations are adopting real-time data and AI-driven insights to manage patient care across the continuum, leading to better outcomes, fewer readmissions, and a more sustainable healthcare system.
A Call for Collaboration
Addressing SDOH requires a comprehensive and coordinated approach from all stakeholders in the healthcare industry. Technology alone cannot solve these challenges, but it is a powerful tool for providing care teams with the data and insights they need to make informed decisions. The benefits for providers, payers, and the healthcare system as a whole are clear.
Moving forward, the key will be to continue pushing the boundaries of what's possible with health tech so we can create a healthier, more equitable future for everyone.
Looking for ways to help your organization identify SDOH patterns and improve health equity? PointClickCare solutions enable high-quality care by pinpointing potential underlying social determinants and alerting care teams for proactive follow-up. Learn more here.
