Social Call: How Digging Deeper Can Help Manage Complex Populations

Social Determinants of Health (SDOH) and the impact on a patient’s overall well-being and care is becoming more prominent and focused as physicians and other caregivers manage health over the life of the patient. No longer do we think of a patient as “healthy” or in some level of disease state in isolation, rather we explore the impact their environment has on them and how it interferes with good health — or prevents them from seeking appropriate care. Increasingly, other factors are impacting the overall health individuals, broadly referred to as social determinants of health. A generally accepted definition of SDOH is as follows (Wikipedia):

Social determinants of health are linked to the economic and social conditions and their distribution among the population that influences individual and group differences in health status. They are health promoting factors found in one’s living and work conditions, rather than individual risk factors that influence disease.

More simply, environmental factors such as housing, food, and finances are just as significant an influence on our overall health as items related to disease state. In this blog series, we will examine the impact of SDOH, first by defining and exploring the origins and definitions of SDOH; second, the impact on physicians and patients in the context of clinical practice; and last, the emerging technologies associated with SDOH.

In the fall of 2015, CMS required the coding of claims for reimbursement using ICD-10. This significantly expanded the number and specificity codes available to more accurately describe a healthcare encounter, including ‘Z’ codes, which provide a series of related potential issues due to family and other social circumstances. The Z codes cover a variety of SDOH including (but not limited to) problems related to housing, extreme poverty, low income, homelessness, inadequate housing, lack of food and safe drinking water, occupational risk factors and insufficient social insurance, and welfare support.

By understanding and collecting this information, organizations can better plan and manage for population health initiatives and create an overall improved experience for patients; better health means means better outcomes and quality scores, as well as reduced costs. It’s important for organizations to create a clear plan and process for data collection and aggregation on SDOH, as it’s a critical next step toward changing healthcare and refining the value-based method of payment.

As organizations take on increasing risk and are involved in other complex programs such as Medicaid, the inclusion of SDOH factors is critical — it’s evaluating the entire person. For example, a patient who is chronically sick may first appear to have symptoms that warrant specific treatments and medicines. Taking a closer look, and incorporating SDOH, may reveal that the patient has poor nutrition due to a lack of access to healthy food. This information can help the clinician determine the best approach to resolving the patient’s problems; they may be able to arrange transportation weekly to a food market. Eating well can contribute to a better quality of life and overall improved health, and limit dependency on medications and expensive interventions down the road. Understanding social aspects, both physical and environmental, is a necessary component of a successful population health management program. has provided guidelines for organizations to use when looking at SDOH. Understanding what to include can help develop programs to assist both clinicians and patients. As with other initiatives that manage populations, a framework needs to be established to support it. There are a variety of ways to do so; HealthyPeople provides some examples of what to consider when building out the framework. The site also includes additional information and detail on creating a program to support SDOH.

Examples of social determinants include:

  • Availability of resources to meet daily needs (e.g., safe housing and local food markets)
  • Access to educational, economic, and job opportunities
  • Access to health care services
  • Quality of education and job training
  • Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
  • Public safety
  • Social support
  • Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
  • Exposure to crime, violence, and social disorder
  • Socioeconomic conditions
  • Residential segregation
  • Language/Literacy
  • Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)

Examples of physical determinants include:

  • Natural environment, such as green space or weather (e.g., climate change)
  • Built environment, such as buildings, sidewalks, bike lanes, and roads
  • Worksites, schools, and recreational settings
  • Housing and community design
  • Exposure to toxic substances and other physical hazards
  • Physical barriers, especially for people with disabilities
  • Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.

In addition to collecting and aggregating data, there are other key considerations, such as what to collect and how, and how to get that information to a clinician at a point where decisions are influenced. There are a number of emerging methods and technologies to collect and organize that information. A more critical piece, however, is getting the data that drives specific insights to providers so that, while treating patients, they can access key information like whether a patient is homeless or has food insecurities, or is missing and has gaps in care. We’ll delve further into that during the next installment.

The first in a three-part series, this piece was written by Renee Broadbent, who is currently Senior VP for Population Health at Holon Solutions. Previously, she served as Assistant VP of Population Health Information that achieved $22 million in savings for the ACO. In future segments, Broadbent will examine the impact of SDOH on physicians and patients in the context of clinical practice, and the emerging technologies associated with SDOH.

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