Technology Provides Actionable Insights for Social Determinants of Health

Social determinants of health (SDoH) are the factors outside of traditional care that impact a patient’s health such as economic stability, education, environment, and access to care. Studies show that over 60% of an individual’s health and well-being are influenced by social determinants of health — but despite the overwhelming impact these factors can have on patient outcomes, 78% of provider executives report that they lack the data needed to identify these risk factors. Giving providers access to the right data can help close the gap between needs and solutions for SDoH. 

One of the largest data sources providers can use to identify a patient’s social determinants of health needs is census data. Using this source, a patient’s address can be to extrapolate information on that area’s average income, education level, and environmental exposure from their census tract. But some critique this strategy believing geographic data is too broad, and that imposing aggregate information onto individual patients may not be indicative of that patient’s SDoH.

While a more narrowly defined geographic unit could help overcome the problem, many providers have also expressed the desire to supplement census information with individual patient screening tools. Tools like health needs’ assessments can screen individual patients for their unique social determinants of health, giving clinicians a way to more accurately identify patients’ needs. Simply identifying these needs is not enough though. Providers need to make this data actionable to help patients. Technology that successfully augments this process should be available at the point-of-care, provide a holistic care plan, and report at the population-level so providers can better manage their patients’ needs.

Point-of-Care Assessment

A patient seeing a primary care provider for a heart murmur expects a referral to a cardiologist at the point of care. The same expectation should hold true for social needs. Providers need the resources to assess and refer patients based on their SDoH when the patient is in the office otherwise, they risk delayed care and poor health outcomes.

Technology can point to a patient’s SDoH needs, but it rarely provides needed information for referrals. Even less likely are the referrals being conveniently located for a patient.

Because accessibility to services is a large social determinant of health, technology aiming to help providers address these needs should use a patient’s self-provided address, at the point of care, to find the closest point for referral and increase the likelihood of using that resource.

Holistic Care Plan Generation

During an office visit, providers and patients should generate a care plan. The best plans are patient-centered and generated through joint decision-making. For a care plan to be truly holistic, it should take into consideration the patient’s SDoH.

For example, a patient with diabetes living in a food desert should receive a care plan to help him better manage his diabetes but the plan should also address his lack of access to healthy food options. Incorporating both the clinical and the social need into the patient’s care plan promotes holistic care and ensures all needs are being addressed, not just the primary clinical need.

Population-level Reporting

Technology leveraged to help assess and refer an individual’s social determinants of health needs should also have the ability to examine these risk factors at a population level. Understanding the needs of one patient will only help improve the health of that patient, but understanding the needs of an entire patient population can help providers identify trends and problems throughout the community that might be alleviated by evidence-based practices or community-level interventions.

Looking at patient needs from an individual and population level allows providers the insight to not only understand what is happening with a particular patient but also the community they are practicing in.

The practice of identifying and treating SDoH needs is becoming just as important as addressing clinical needs. In a value-based world where providers and payers are seeking to improve outcomes and reduce costs, implementing the tools to pinpoint social determinants of health and take action are crucial.

To learn more, download the infographic, Improving health through clinical care.

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Optum works across the health system to drive high quality, sustainable outcomes and manage the total cost of care. Download our e-book, Fast-track your health system performance to read about strategies to support value-based care and improve performance with a  clear, complete view. Learn how your peers are making an impact with innovative strategies powered by data and analytics solutions. Visit optum.com/data-analytics or call 1-800-765-6705 to learn more.