Addressing Social Determinants of Health Requires Population-Based Data

At Community Health Plan of Washington, population health management tools allow the organization to integrate social determinants of health data across its network of community health centers.

Capturing social determinants of health data is a challenge for many payer organizations. Patients might be wary of revealing that information to their insurer or provider. And providers often do not feel comfortable asking patients questions about their housing, access to healthy foods, or transportation if they do not have the ability to recommend a fix.

“Providers don’t want to ask a patient about housing if there aren’t any resources to refer that patient,” said Jennifer Polello, MHPA, PCMH-CCE, director of clinical data integration and social determinants of health at Community Health Plan of Washington. “It’s just an uncomfortable, awkward encounter.”

Community Health Plan of Washington recognized the need to train these providers in addressing patient social needs. But its network of community health clinics made it challenging to truly understand the extent of the problem.

“When we asked frontline staff to expand their services, it became apparent that we didn’t have accurate data on the prevalence or need for social services. The place for us to start logically was trying to figure out how to capture a lot of these social needs,” Polello explained. “A lot of cities are actively assessing patient social needs but it’s not electronically captured in a way that we can combine with our clinical or social data to really understand the true prevalence of the issue.”

In 2017, Community Health Plan of Washington began working with the state to create new codes that identified patient social needs.  

“For claims information, we have the coding that exists in Z codes. We also had census data. We can combine that census data with different chronic diseases and other social needs data,” Polello elaborated.

In total, Community Health Plan of Washington and its state partners created 59 new codes. And once these codes were finalized, the plan began educating providers on how to properly document them.  

“We’ve created and distributed a number of coding guides around social determinants and how to use those codes,” Polello said. “It doesn’t have to be the provider who documents those. Encouraging the care team, social workers, nurses, and medical assistants to get involved in the documentation of the Z codes is really going to help build up the data and build a case to increase those provider and community resources.”

Without documentation, Community Health Plan of Washington could not fully understand the needs of its patient population. So frontline staff at the plan’s community health centers began working with patients to complete assessments that captured this information.

“We’ve had a lot of success with deploying these assessments with medical assistants or support staff who can help complete these surveys,” Polello explained.

Once all of the data was captured, Community Health Plan Washington used population health management tools to aggregate and analyze the state of their patient population.

“It’s a tool that integrates the 20 electronic health records from our community health centers,” Polello continued. “It matches up different EHR sources and clinical sources.”

That allows the plan to understand the needs of its entire population, deciding where to divide resources based on need. It also allows the plan to stratify its patient population based on gaps in care and conduct appropriate outreach. Polello’s team is also using the information to understand trends across the network of community health centers.  

“We’re able to have a lot of visibility about our patient population across the network,” she said. “This is the foundation that’s allowed us to expand our vision and our functionality in terms of how we’re able to pivot for different social needs based on this population health platform.”

Now, the organization can work in partnership with the providers and staff at community health centers to disseminate resources to patients.

“We are working to stand up a virtual network of resources across our state to help with the awareness and visible referral pattern of these social services,” Polello said.

Organizations may find it overwhelming to tackle every social determinant of health at once, especially when they see how expansive the social services network can be. So Polello recommended beginning with one social determinant of health, maybe the most prevalent.

“Create workflows and workflow aids and education around just one social issue to start the ball rolling,” she said.

Regardless of the strategy employed, building this network of community resources to address social determinants of health is important now more than ever. Layoffs and job cuts because of the coronavirus outbreak mean more individuals are in need to added assistance.

“Community-based organizations are struggling right now. We want to work with them to virtually provide these services where appropriate and maintain this network across the state so providers can feel more comfortable and empowered to ask these questions and help identify where the need is,” Polello concluded.