Erin Benson

Posted on: December 27, 2018

Right now, patients are awaiting discharge from your busy units.

Right now, your nursing staff, physicians and discharge planners are determining plans for your patients to follow when they leave the hospital.

Can they be followed? Will they be followed?

How do you know their life circumstances won’t cause them to return and need additional care?

What if you could understand what was waiting for those patients when they arrived home? What if you had insights that would allow you to arrange reliable transportation to their follow-up appointments? Or to know if they have access to healthy food or live in high crime neighborhood?

The challenge of population health management

As much as hospital staff care about the patients they treat, our overtaxed healthcare system can’t handle the burden of ensuring such factors as reliable transportation, medication compliance and stable housing. The term social determinants of health data (SDOH) is in a different news article almost every day because the industry recognizes the value of these factors in care management.

The numbers don’t lie. More people are paying attention to what factors outside of the medical condition itself contribute to the risk of readmissions. Because that is how we’ll improve health outcomes and cut down high costs.

A study in JAMA Internal Medicine determined that 27 percent of all 30-day readmissions are preventable. So where is the disconnect?

Even the Centers for Medicare and Medicaid (CMS) has stepped in and recognized the problem—enacting the Hospital Readmissions Reduction Program (HRRP) in 2012. Although readmissions declined under HRRP initially, these declines have now flattened out. So, something isn’t working.

We must properly implement the available data

Medical care determines only 20% of overall health, while social, economic and environmental factors determine 50 percent of overall health1. We know these social and economic factors are critical to a patient’s wellness and a path to better population health. What providers don’t always know is what they are and how to quantify them.

As a result, not all SDOH data is created equal. In an already data-overloaded world, is there a solution that can begin to integrate this data and layer analytics on top of it to create critical insights for care planning that can be made actionable for care teams?

The answer is yes there is! And it has to go beyond clinical and EHR data.

Social determinants of health alone are a powerful tool in care planning

Utilizing that data in analytics to identify a patient’s chances of readmission could be a game changer for provider organizations.

What we often hear from our provider customers is they see the value of SDOH data, but need to be able to make real-time decisions.

Real-time, insightful and informed readmission risk stratification scores based on SDOH are the “right now” answer we need. Social determinants of health data help identify the patients who are heading for readmission to a hospital within thirty days.

Socioeconomic attributes can also create health alerts and then identify actions to prevent those readmissions. Thereby allowing your organization to work towards the much-talked about and seemingly elusive goal of truly improving population health and cutting healthcare costs for the long-term.

We can make it happen. Let us show you how.

1 - Bridget C. Booske et al, “Different Perspectives for Assigning Weights to Determinants of Health,” http://www.countyhealthrankings.org/sites/default/files/differentPerspectivesFor
AssigningWeightsToDeterminantsOfHealth.pdf, (February 2010)

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