Social Determinants 101: The Absolute Necessity of Modern Healthcare

Race, gender, socioeconomic status have been known to affect a person’s health, access to care, costs incurred, and the outcomes. The defining conditions of how we live, learn, work, and play not only influences our health but goes on to define and impact an entire community’s health.

However, social structures and the surrounding environmental conditions, right from a person’s ethnicity to their work can impact key areas that can result in unequal care delivery. As healthcare moves towards targeted, value-based care delivery, it’s important for providers to understand social determinants and gain momentum into designing critical parts of care delivery.

The Five Denominations of Social Determinants

The social determinants of health (SDOH) shape and affect the distribution of ethnicity, money, power, and resources. SDOH can be grouped into five major groups:

• Economic Instability: Poverty, employment, food security, housing stability
• Education: High School Graduation, Enrollment in Higher Education, Language and Literacy, Early Childhood Education and Development
• Social and Community Context: Social Cohesion, Civic Participation, Discrimination, Incarceration
• Health and Health Care: Access to Health Care, Access to Primary Care, Health Literacy
• Neighborhood and Built Environment: Access to Healthy Foods, Quality of Housing, Crime and Violence, Environmental Conditions

In a nutshell, the social determinants of health have a major accountability in an individual’s ability to understand the importance of healthcare. It directly connects to the availability and access to care and enhancing their health.

The Challenges in SDOH

U.S. spends the most on healthcare and still experiences a lower life expectancy and higher infant mortality rates than countries as developed as the U.S. There are some strategic challenges with SDOH providers frequently face:

• Lack of knowledge and consensus: More often than not, there is no precise mechanism, standards, or tools to implement broad patient-level programs. It is of utmost importance that defining data about social determinants affecting people’s health is present.  
• Difference between social services and healthcare organizations: Healthcare organizations and social services share a common set of goals when it comes to delivering value in healthcare. The absence or poor communication between organizations creates gaps in care delivery.

• Lack of a common alignment: Absence of a consensus on many fronts creates confusion. Other questions like who will collect data and how, how will it be made available to providers, and how to connect patients with figures still prevail. Moreover, patients’ consent could also be a roadblock.

• Rigid technology: There is a need to develop the right kind of technology to collect data and identify anomalies across patient data. Moreover, it’s vital to have a platform much evolved than EHRs that facilitates analytics and data sharing.

Why do we need to focus on Social Determinants?

Social Determinants have been ignored by many for reasons questioning their capability to produce a substantial effect on the clinical outcomes. In the past, it has been proven that by incorporating the social determinants of health in care framework can help in understanding the complete picture. They help in figuring out major causes behind why a specific set of the population is becoming ill initially, and, moreover, could play a handy role in restoring their health. With social determinants, it becomes easier to recognize the value of economic conditions and demography are as essential to staying healthy.

Preventive care could be an important piece in solving the big puzzle of healthcare. A value-focused organization in Minnesota began enrolling patients in its Social Determinants program. The aim was to increase the preventive care and to reduce preventable hospital admissions, and emergency department (ED) visits for vulnerable patients. The organization used various care coordination model to meet patients’ physical, behavioral, social, and economic needs. Within one year of the implementation of the program, ED visits were decreased by 9.1% and outpatient visits increased by 3.3%. Therefore, it goes without saying that addressing just the symptoms of diseases and ignoring its root cause will not improve population health in a longer term.

Leveraging Big Data to Manage Population Health

Managing and countering social determinants of population health is critical to improving health outcomes, bridging care gaps, and reducing costs. Healthcare has long focused on using big data to deliver outcomes and with a rapid transition. To bring value-based care underway, harnessing data sources to collect physical, behavioral, and socioeconomic health information has become critically important. Here’s how health IT and big data can help providers determine the impact of social determinants:

• Integrating data from disparate sources to understand the population composition and stratify people into groups according to the risk score. Practices can be attentive to the underlying factors that shape patient and community health and gain more information about what would benefit the patients.
• Provide a complete picture of a patient’s lifestyle in a consolidated form and putting together a care team to track SDOH.
• Create awareness and visibility around both clinical and social services about the impacts of these determinants.
• Engage health IT services to provide prescriptive analytics addressing the gaps in care.
• Patient data, complete with SDOH information permits a better understanding of challenges each patient face in pursuit of health. By identifying the resources, they need to build we can sustain value-based outcomes.

A healthcare organization based in Minneapolis focused its efforts to improve physical, behavioral, and socioeconomic aspects of care using health IT. Their efforts have resulted in a reduction in ER visits, increased attention to preventive care, and improvements in overall population levels. They also managed to save $2.44 million within two years!

The Road Ahead

It wasn’t until we had the technological prowess to deal with the increasing population, we found innovative solutions to deliver better clinical outcomes. Today, from where we are, we can not only predict the cause of a disease but also who is it going to affect! Healthcare is changing rapidly, and we need to be future-ready to create impact at scale. Social Determinants have proven to be a major stepping stone for preventive care and improvising on it could really mean a big win for everyone.

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