Capturing Social Determinants of Health to Effect Lasting Change

Providers and payers have come to the realization that effecting system change requires a more comprehensive understanding of the patient beyond the clinical encounter.

Social determinants of health play a significant role in whether a patient is able or willing to adopt behaviors likeliest to improve his health status.

“Health actually begins where we live, learn, work, play, pray,” Parkland Center for Clinical Innovation President & CEO Steve Miff, PhD, said during a recent episode of Healthcare Strategies, an Xtelligent Healthcare Media podcast.

“But the knowledge and solutions to act in a way that both supports an individual and also drives systemic change, have been elusive because it's outside of our core training,” he continued. “It's outside of our areas of influence. It requires us to reach and work with the vast array of organizations across the community.”

PCCI is an offshoot of Parkland Health System in Dallas, borne out of the idea that specialized tools and resources were necessary to identify and remove barriers to well-being among vulnerable populations.

According to Miff, progress begins by developing a full picture of the individual and his community “so we can appreciate not only the choices an individual has but also influence and support the decisions that we're guiding them to make.”

This knowledge informs meaningful engagement. “It's proven through behavioral sciences that engaging an individual in decision making and choices is much more effective than dictating a course of treatment,” he added.

A significant challenge for providers and payers is capturing these social determinants of health. At PCCI, Miff and his team engaged with the Robert Wood Johnson Foundation to improve the health of individuals with hypertension and diabetes who were also facing food insecurity.

“We use both the technology and the system that we've built in Dallas to connect those individuals to food pantries and share the information about the medical condition when the referrals were made for the nutritional support,” said Miff.

“When they showed up the various food pantries, we created a new process so the food that was provided and the guidance was based on their medical condition. At the same time, we provided those volunteers at the food pantries with information about their upcoming medical appointments, so they can also remind them about their follow0up appointments and also inquire whether they had a way to get there.”

And the results were quite positive. The PCCI project saw a 50-percent reduction in readmission for those patients who reported feeling empowered by the experience.

“They felt that they should care more about it themselves,” Miff revealed. “And while the volunteers were initially skeptical about taking on that added responsibility, their satisfaction with the services they provided after the training increased significantly.”

Miff is optimistic that the strategic combination of cutting-edge technology and community-based intervention will be key to ensuring equity in care and healthier outcomes across populations.

“We will be better in understanding who are our patients beyond clinical diagnosis,” he concluded.

Listen to the full podcast to hear more details for turning social determinants of health data into action. And don’t forget to subscribe on iTunes, Spotify, or Google Podcasts.