We know social determinants of health programs are critical to improving outcomes for marginalized patients. There’s the patient who lives in a high-crime neighborhood, who may fear for their safety while walking to the drug store. Or doesn’t have access to a car to attend a follow up appointment. Or has moved frequently and doesn’t have an established pediatrician, so uses the hospital ER for their kids’ primary care needs.
When organizations are able to analyze data on these patients’ healthcare activities, but also the social determinants that impact their lives outside of the healthcare system, they can really understand the patients’ barriers to care — and take steps to assemble resources that will improve patient outcomes.
Too often, organizations are stymied in setting up SDOH programs. Because of the sheer volume of data available and the limitless possibilities for analysis, organizations are torn over where to start, which ultimately leads programs to stall.
Should you address medication adherence or transportation access needs or another social determinant? Social determinants of health data can help you evaluate needs at the population and individual levels to help make these decisions.
Jump-starting the Process
The best data can guide your decisions, providing confidence at every step. To help, LexisNexis Risk Solutions has developed a playbook to outline 3 steps you can take to create an effective SDOH program.
Step One – Select the Focus of Your Initiative
First, identify which population and health outcomes to target. Focus on clinical conditions and outcomes that significantly affect your patient populations. Look for groups that may be impacted by costly hospitalizations, high levels of hospital readmissions, or disease states that are negatively impacted by medication noncompliance — conditions that lower quality of life, that can be positively impacted by intervention.
For example, you might focus on diabetics only within your population. Or you might narrow your analysis even further to a population within a single location, like diabetics in Orlando.
Step Two – Match Existing SDOH Programs to Patient Needs
When you’ve decided your focus, you must determine which resources will address the patients’ barriers to care. Do patients need transportation for follow-up appointments? What social services already exist to help them, at your organization or in the community at-large? Should your organization consider aligning with community services to further scale the assistance? Or does it make more sense to build out your own service?
Matching programs with existing needs has been shown to be effective in improving patient outcomes. You can measure success by weighing how well internal programs and community partnerships cover these needs. Then consider establishing new programs and partnerships to cover additional barriers or expand on existing services. Certainly, there will be cost involved — but there will be considerable ROI when health outcomes are improved.
Step 3 – Coordinate Care by Tailoring Health Services to the Individual
When at-risk patients are connected with clinicians, social workers and community resources, you’ll see the biggest impact on health outcomes. At this stage, it is critical to work with clinicians to ensure they know how to access and apply SDOH data to improve outcomes.
It’s also important to measure patient engagement; are patients following their doctors’ advice? are they using services available to them? and have their health outcomes improved?
Drive Value and Cost Savings with Social Determinants of Health Data
Getting an SDOH initiative off the ground requires a lot of thoughtful coordination between analytics teams, clinicians, social workers, and community partners, as well as buy-in from leadership.
With the best data, you can identify “quick win” projects to kick-start your efforts. You can also identify estimated ROI, and define metrics to demonstrate success. Implementing small, measurable initiatives helps to start making an impact right away — then figure out how to scale that into bigger, better programs for even greater cost savings and positive health outcomes.
With the new year upon us, there’s no better time to invest in detailed SDOH data that will guide those critical first steps. Just imagine, 12 months from today, how your C-suite will view this initiative — especially if it’s guided by the best data available. You’ll have made a long-lasting positive impact on your target community, with a nice return on investment.
Click here to access our playbook, 3 Steps for Building an SDOH Business Case.