Integrating Social Determinants of Health into PHM

Integrating Social Determinants of Health into PHM


With the transition to value-based care, risk adjustment has evolved past historical evaluation of patients by age and sex – female patients tend to use more primary care time and resources, and older patients need more time – to now factoring multiple medical co-morbidities, medications, ER visits, social determinants of care and hospitalizations. The importance of socioeconomic and environmental factors cannot be underscored enough. Data from the Kaiser Family Foundation reinforces this, finding that 60% of a patient’s total health is determined not by their clinical conditions, but by other social determinant factors. According to the Robert Wood Johnson Foundation, socioeconomic and environmental factors determine 50% of a person’s health outcomes; clinical intervention impacts only 20%.8802-figure-1

A Moody’s Analytics report published in December linked the social determinants of health to patient’s vulnerability to chronic diseases and other clinical conditions. The report analyzed county-level socioeconomic factors, including age, race, education, family structure, average annual pay, employment rate, population density and 10-year growth in income per capita. Among its findings, high cholesterol, coronary artery disease, hypertension, chronic obtrusive pulmonary disease and diabetes were found to have a strong relationship with socioeconomic and behavioral factors. As the report notes, better health is consistently associated with a strong economy, higher pay, and less densely populated areas. Poorer counties mean poorer health, which often means that individuals experience higher burdens from their health conditions. As David Nash, MD, MBA, dean of the Jefferson College of Population Health, noted, “The most important five-digit number I need to predict your health status and well-being is your zip code, bar none.”

Social Determinants of Health

Unfortunately, health organizations including insurance plans and health systems do not have great data on these factors. The challenge lies in identifying sources of this data and incorporating into the data warehouse along with clinical data from the EHR and claims data from payers. Algorex Health outlines publicly available data sources that can be pursued, including government geographic sources such as the census bureau, CDC, supplemented private geographic sources, and individualized data.

A recent Change Healthcare survey polled respondents regarding integration of social determinants into their population health programs. The results show a variety of strategies being employed to integrate social determinants of health, with 42% including community programs and resources; 33.7% integrating medical data with financial, census, and geographic data to better understand their patient populations; and 33.1% offering social assessments with health risk assessments.

HCO integration social determinants of health population health management

If providers are to have a chance of implementing effective population health management strategies, social determinants of health that help to take the “vital signs” of a patient’s community must be integrated into the electronic health record. Better integration between traditional clinical data and community-level information is needed, with a more comprehensive and standardized approach to integrating socioeconomic data into the EHR and point of care. Achieving this integration facilitates interventions, which leverage social services to improve health and reduce cost. Timely interventions in the areas of housing, income support, nutritional support, and care coordination and community outreach through community health workers can have a profound effect and positive impact on population health.

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