Every day patients enter healthcare facilities all over the country as nurses, doctors, and other healthcare personnel work diligently to ensure they receive optimal patient care. But, 50% of healthcare outcomes are based on patients’ social, economic, and behavioral decisions, and not on the clinical care they receive.

While healthcare leaders recognize the significant impact of non-clinical factors on patient overall wellbeing, many struggle to properly leverage this data. But when adequately addressed, it helps providers boost medication adherence, reduce hospital readmissions, and enhance engagement among all patient populations.

Even when patients receive excellent care, if they’re being sent home with no access to transportation or no family support, and they live in an isolated area, the odds of readmission are high. Consequently, this leads to increased healthcare costs, lower value-based quality scores, and most importantly, poorer patient outcomes. Because of these things, healthcare organizations have a huge incentive to close the gaps in patient care both inside and outside of the hospital.

Social determinants of health (SDOH) can help care providers predict patient risk and address potential issues before they become problems. While there are benefits to addressing SDOH, I recognize that building out the business case may not be easy.

Rich Morino and I recently co-presented at the RISE National Summit on SDOH on this very topic and here are some of our recommendations for implementing a program if you’re not sure where to start:

Define What Success Looks Like

As with any project, the first step includes defining what success looks like – and whom it will benefit. Then, design success metrics based on key stakeholder requirements. We propose analyzing along four defined stages of a patient’s care journey: 

  • Recognize health, wellness, and risk through SDOH analytics
    Gather insight into why someone might be at risk looking at social determinant factors like education, neighborhood, social and community context, and economic stability.  Use risk scores to help healthcare providers close gaps in care and improve clinical quality scores. Define metrics that will resonate with quality and analytics teams.
  • Map community resources and identify gaps
    Align patients (or populations) with the resources they need and close gaps in care to provide continuity of care even outside of the facility. Identify or develop community partner relationships that can impact the care gaps. Define metrics that will appeal to population health management teams.
  • Customize health services and interventions
    Customize interventions so that they are appropriate for the patient. Develop metrics that will help clinical care team members understand how well SDOH helped them to engage patients in their own health decision and/or how successfully those patients followed care plans/recommended interventions.
  • Assess Service and Impact
    Identify how well your programs worked overall. Define metrics that will resonate with your organization’s leadership. Were quality ratings improved? Did you see an impact in revenue and reimbursements? Were costs reduced?

Quantify the Value of your SDOH Program

SDOH poses tremendous opportunities for healthcare organizations to better help their patients as well as gain a competitive advantage. For instance, reduced hospital readmissions mean cost savings for both healthcare facilities and the patients they serve. While improved medication adherence not only increases positive health outcomes, it can impact a $300B US healthcare problem. Improved health outcomes also improve quality scores.

When SDOH are proactively addressed, everyone reaps the benefits. For instance, identifying patient barriers to obtaining proper care helps to predict which patients are at greater risk for hospital readmission, or medication non-adherence.

Knowing which population is at risk allows healthcare providers to engage patients and propose solutions or interventions that will lead to better health outcomes.

For example, if a patient lives alone and in a rural area where he doesn’t have quick access to a pharmacy, or reliable transportation for follow up doctor’s appointments, it’s statistically more likely that he will have difficulty adhering to his medication regimen and/or following appropriate post-care instructions. Instituting a mail-order pharmacy service and/or facilitating ride share could make a significant difference to that patient’s health.

It’s important, as SDOH programs are developed, to make a financial case for investment. Understanding (and explaining) how investment on the front end can lead to cost savings and improved health outcomes is imperative to success.

In our session, we walked attendees through a series of exercises to highlight how best to do that – showing how, for instance, having patients “teach back” their discharge instructions to healthcare providers can cost as little as $33 per patient, but create an approximately 30% reduction in hospital readmission.

Incorporate SDOH into Your Workflows to Improve Clinical Care Outcomes

Adopting SDOH into your current practice improves care management and predictive models. When we know the conditions under which our patients live, work, and play, we can improve patient outcomes and experiences across the board.

Addressing SDOH begins with using clinically-validated data to evaluate patient needs on an individual level. This helps care providers make key decisions about which health outcomes to address and what types of programs to utilize for their patients.

We encourage healthcare organizations to “think globally but act locally.” Start by looking at entire populations to determine which areas to address and then create SDOH programs/models towards patients with specific health barriers where you have programs already in place and/or can easily put into place. For instance, non-emergency transportation programs may be a quick win.

Finally, to make the greatest impact, focus on the areas where incorporating SDOH data can impact quality scores, since quality score improvement will ultimately impact the bottom line.

The most important takeaway here is that now is the time for healthcare organizations to incorporate SDOH into their clinical workflows. Doing so can save time, money, and resources; it can increase patient engagement; and, overall, it can improve patient care. The biggest potential pitfall is “paralysis by analysis,” or doing nothing because you can’t do it all. Pick a few areas of focus as a starting point – such as a combination of a medical condition (e.g., Heart Failure) and a health outcome to improve (e.g., reducing readmissions) – and align to existing social initiatives where possible. Look for ways to evaluate potential cost reductions, and use available studies on SDOH impact on health outcomes to estimate potential impacts. Add on new programs once you get the hang of the first ones. Just don’t wait – find a way to begin.