Vice President & GM,
Population Health,
Caradigm,
an Inspirata
company
According to the U.S. Department of Housing and Urban Development, 549,928 people are homeless in the U.S. on any given night. Lacking basic resources and support networks, these individuals are five times more likely than nonhomeless individuals to be admitted to a hospital inpatient unit and stay an average of four days longer, at a cost of $2,000 to $4,000 per day.1 Across the country, hospitals are stepping up to deal with homelessness and whittle down accompanying high medical utilization costs. These efforts include providing post-discharge respite care, offering residential case management, and donating money to build new housing units for homeless and low-income individuals.
There has been an increasing amount of discussion recently around social determinants as a means to improve population health while reducing healthcare costs. Despite today’s buzz around social determinants of health (SDoH), the idea of social determinants is not new. Social determinants have historically been considered a public health issue, and many government health departments developed programs to address health needs based on these factors. While many of these programs have lost momentum, social determinants are reemerging as a key focus in public and private industries to improve value-based care outcomes.
The factors of SDoH are far-reaching, and the impacts are considerable. According to the Institute for Clinical Systems Improvement, the overall set of factors that go into a patient’s health include the following:
- Healthcare: 20% is based on the quality of care that the patient receives
- Health behaviors: 30% is based on the patient’s health behaviors (e.g., do they use tobacco, exercise regularly, drink alcohol)
- Physical environment: 10% is based on the patient’s physical environment (e.g., the neighborhood they live in, their housing situation)
- Socioeconomic factors: 40% is based on socioeconomic factors (e.g., education, job status, literacy)
Beyond medicine: Additional health factors
When you combine the physical environment and socioeconomic factors, 50% of the contributing factors that impact the patient’s health are unrelated to their medical care.
So, how do healthcare organizations gain insight into the socioeconomic conditions of their patient population? Organizations can either offer patient assessment questionnaires or implement digital solutions with SDoH analytics. There are a handful of patient assessment options, such as the Accountable Health Communities Health-Related Social Needs Screening Tool from the Centers for Medicare and Medicaid Services and the Protocol for Responding to and Assessing Patients’ Assets, Risk and Experiences from the National Association of Community Health Centers. While these assessments ask questions that aim to understand the socioeconomic conditions of the patient, it is important to consider that the patient might not have a full appreciation of their current condition as it relates to norms, which may impact how accurately they fill out the questionnaire. Further, considering that 50% of patients withhold information from their doctor,2 it is risky to depend on self-reporting assessments alone to evaluate the risk of the patient.
Digital solutions for SDoH
The alternative is to use digital solutions that mine data through analytics to inform and identify these risk factors. Analytics vendors leverage public data such as DMV reports, court records and census data, as well as third-party data such as consumer marketing, real estate data and credit information. These vendors run a minimal set of patient information through their analytics engine to return stressor scores and information, evaluating patient risk in areas such as:
- Health literacy: The risk that someone will not be able to comprehend topics or discussions related to their medical condition, risks or care plan
- Food access: The risk that someone will not be able to feasibly travel to and afford a grocery store that has healthy fruits and vegetables
- Transportation: The risk that someone will not be able to make an appointment or receive medical services in a nonremote locale because travel was not feasible
- Home stability: The likelihood someone has been evicted or is under financial threat of eviction or foreclosure due to costs of housing
- Financial stability: The risk that someone will not be able to afford medical bills or other expenses related to health maintenance
As patient information is run against data from thousands of contributing indicators, healthcare providers can gain insights into their entire patient population, leveraging well-defined algorithms that are free of any biases introduced by survey data. Stressor scores inform providers about at-risk patients in their population, allowing the care team to take preventive action, resulting in better health outcomes. If a patient has high transportation stress and high financial stress, the individual is more likely to be a no-show at post-discharge appointments. If a patient has high food access stress and high health literacy stress, the individual is less likely to have a consistent and nutritious diet. By identifying patients at high risk of readmission or chronic disease, the care team can more closely monitor these patients and take action when needed to prevent and manage disease and illness.
Looking at healthcare differently
We cannot continue to deliver care in the same manner that we always have. We have to look at healthcare differently. Identification of patients that have socioeconomic risk factors is half of the battle in ensuring patients’ needs are addressed. SDoH information needs to be made available to all members of the care team—the patient’s physician, care manager, social worker and pharmacist. Further, the care team must be able to act in response to the patient’s needs through a unified plan of care that is influenced by social determinants. Many organizations are reaching out to the community to meet patients where they are: Providing mobile clinics, mobile labs, mobile pharmacies and guidance on housing services. As socioeconomic factors make up 50% of a patient’s overall health, identifying at-risk patients, understanding their needs and putting the right programs in place are crucial to improving patient health, reducing overall healthcare costs and cultivating communities. By understanding social determinants, we can improve healthcare for all of us.
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