Best Practices to Develop a Social Determinants of Health Strategy

Promote buy-in at all levels

Strategy implementation requires organizational buy-in from key stakeholders involved in the implementation of the strategy. The challenge with a SDOH strategy is that it requires buy-in from both within and outside the organization. Providers are often the ones implementing the strategy and the larger health care industry needs to support a focus on the SDOH. 

At Humana, leaders needed three key levels of buy-in in order for their SDOH strategies to succeed, according to Andrew Renda, MD, the associate vice president for Humana’s population health strategy.

“On the one hand, we have internal stakeholders, because we had to convince our management team that they want to invest in social determinants of health for our members,” Renda told HealthITAnalytics.com.

“Then we have physicians. Buy-in there is education about how social determinants of health impact health and health outcomes. It's convincing them that we’ll support them with the data analytics and the referral sources that they need to maintain the relationship with their patients. The third stakeholder is CMS and convincing them that social determinants are important, that there’s a clinical case, a business case.”

Buy-in from within the organization was simple for Humana as the request for a SDOH strategy came directly from the CEO. But getting buy-in from other stakeholders proved more challenging.

To generate provider buy-in, Humana built a continuing education course to give providers an overview of why social determinants are important for health, walking providers through validated screeners for social determinants, coaching them on best practices and how to have conversations about screenings with patients, and offering referral resources.

Buy-n required a larger shift in the healthcare industry to get CMS on board, Renda said. As more research revealed the importance of social determinants of health and more organizations began to address them, it was easier for Humana and CMS to work together.

Caraline Coats, vice president of Bold Goal and Population Health Strategy at Humana said obtaining buy-in for a SDOH strategy was easier because there was a shift in the industry’s emphasis on social determinants of health.

“It’s a mindset change not just for Humana but for our industry,” Coats stated. The industry began to look at gaps in SDOH the same as gaps in clinical care.

Draw data from multiple sources

Next, Humana needed to outline its strategy, and in order to do so, it needed ample patient and SDOH data.

Data helps make a case for buy-in, demonstrates targeted goals and a means of measuring the goals, shows key improvement areas, and helps monitor outcomes. If just beginning a SDOH strategy, though, data on a specific member’s SDOH may be difficult to obtain.

Humana utilized large amounts of publicly available data.

“We get data wherever we can,” Renda remarked.

Humana worked with the Robert Wood Johnson Foundation’s county health rankings and the census data to understand the unmet social needs in their various markets. They synthesized this data, as well as member collected data through routine telephonic surveys and home visits.

But payers need to be wary of “analysis paralysis,” Coats warned, noting that too much data can shift the focus from making a change to overanalyzing data.

“There’s so much information out there right now,” Coats explained. “We’re all trying to prove the relationship between health outcomes and social determinants of health. I think we know the answer and that there’s value. The question is what is the value? We’ll answer that question eventually, but we have to go in with the assumption that investing in social determinants of health has value.”

While obtaining data from all sources and utilizing data collection tools that already exist help to inform strategy, becoming inundated with the data can stall improvement plans.

Encourage community involvement

The next step for Humana was picking up community partners. Implementing a SDOH strategy requires community involvement to help identify areas of need and community resources to aid the strategy.

“Health care is local and it is even more so when you're addressing social determinants of health,” said Coats. “Whether it's anxiety and depression, stress in a market that's prone to hurricanes, or a market that has a higher prevalence of suicide, understanding with whom you need to build trust to develop a collective impact and rally around is fundamental to scaling and operationalizing a strategy.”

A community-based organization might be trying to address the same problems as a plan’s SDOH strategy. These organizations receive grants to fund their work and look for partners to aid in their mission. The options within a community are abundant and partnering with local organizations will allow both parties to accomplish their goals.

“There are community resources that you have easy access to, or you can figure out the resources within your own specific geographic area,” explained Renda. “There are food banks everywhere. There are community centers everywhere. You just have to figure out where those are. A lot of those are no-cost. It doesn't necessarily require a lot of money.”

Those in a community understand best what a community needs. Having a relationship with the community will help grow an SDOH strategy and can even point to areas of improvement a payer might not have thought of originally.

“I see now in our most mature markets, those relationships that we've now been nurturing and working on and building, they're paying off not in a business way but through innovative ideas to co-create solutions on how to then tackle these social determinants of health. We would have had never had the idea to approach them in such new ways. That local presence and focus is really important,” stated Coats.

Remember that good things take time

SDOH impact health in the long run, not necessarily the short-term. The effects of an SDOH strategy might also take several years to see results that ultimately impact the business case for investment.

“This isn't something you can just flip a switch and turn on overnight. I think an important piece to underscore to anyone who's taking this on is it takes some time to invest in local markets,” Coats said.

Being flexible and open to building the strategy simultaneously with new data and analysis is what has helped Humana succeed. Their strategy is adjusted in real-time as new research is published and new community organizations begin partnerships. 

“We’re building the plane as it’s going down the runway,” Renda noted.

Tuning a strategy based on new insights rather than being anchored to a specific plan will help a strategy succeed.

Build for the future

When Humana began undertaking its Bold Goal Initiative, the payer set its sights on a 20 percent increase in health by 2020. Now that the initiative has been successful, the health plan is starting to make a new strategy focused on sustaining success and continuing to improve the health of its populations.

Implementing SDOH monitoring and referrals into routine practice is one way Humana plans to continuously sustain its program. If providers are regularly monitoring the social needs of their patients and have the proper tools for referral, the strategies implemented by Humana become a part of the routine workflow and no longer need to be heavily monitored by the plan.

“One really good and efficient way to scale is actually by integrating social determinants into current clinical operation models. We can scale really quickly if we’re integrating directly into established clinical programs,” said Renda.

For example, the payer’s Humana at Home program, which serves as a care management program that helps members remain independent at home, leverages community health workers to track SDOH. While those home care workers coordinate medication, clinical care, and other routine tasks, they also screen Humana members for SDOH needs, allowing for a more holistic view of the patient.

Humana has also developed a population health department which has now become a part of its budgeting framework. Development of this department integrates population health and SDOH into the framework of Humana’s organizational structure making it a part of long-term investment plans.  

This sustainability will improve as the health care industry continues to shift from a fee for service model of payment to a more value-based payment system.

“We’re just now seeing maturation in different value-based models,” Coats concluded. “We are diligently working with our value-based strategy team right now to co-create some different value-based payment models that include social determinants of health screenings or referrals or not necessarily one model. It depends on what physicians are doing today and what resources they have and what capabilities they have.”