Connecting the Dots for Social Determinants

Social determinants of health are receiving some much-needed attention, with stakeholders across the industry looking for ways to better address the whole health of individuals. While the components being addressed are nothing new (transportation, food, shelter, etc.) it’s the increased focus by healthcare professionals to do something about it that is causing quite a stir.

The challenge
We’ve seen a lot of the conversation focused on the collection of social determinants data, and the digital exchange of that data. Unfortunately, at this time, providers aren’t well equipped to do much with the data nor are they incentivized to collect it. In fact, with concerns over physician burnout already brewing, adding responsibilities for social determinants might be calamitous. While there is much speculation that addressing social determinants will improve provider satisfaction, as they help their patients achieve health, the frustration of capturing the data with no ability to fix the problem could be disastrous and end-up increasing the burnout. The collection of this data isn’t necessarily new, though. Many healthcare organizations have been gathering data on social determinants of health for decades through health risk assessments and things of the like. But at the end of the day, it remains that the data isn’t yet being shared or used to make any short- or long-term improvements.

Moreover, partnerships between providers and social and community entities are few and far between, making it difficult to connect patients with those organizations even if the need has been identified. Even once the right resource has been identified as the best way to help a specific need, provider organizations are having difficulty placing patients with those resources. It’s not enough to just tell a patient about those resources or give them a pamphlet; steps need to be taken to ensure that the patient has access to those resources and has a real, tangible opportunity meet/see/visit that community resource.

For example, one of the largest social determinants is whether a patient has transportation to needed or prescribed care. Too often, patients, especially in the Medicaid and Medicare space, know what care they need, but lack the ability to get there. How do we expect patients to move forward in the care process if they don’t even have the means to travel to where they need to go?

What can we do?
Taking a step back and looking at some of the recent advancements that have been made in the way patients access care can perhaps shed light on how we can better connect with resources like transportation. We’ve seen tools like digital referral scheduling and online patient self-scheduling make it easy for patients to access primary and specialty care across disparate provider networks. Perhaps this same technology can extend into connecting with resources that address social determinants?

What is needed is the whole package. A means to collect the data and identify the social determinant that is affecting, or could affect, the patient’s health – then an easy way to schedule a time to meet with the resource that can solve for that need. Continuing with the transportation example above, imagine the following scenario: after arriving at a provider’s office, a patient is presented with a tablet on which they answer a brief survey about their social determinants/needs. That information is then used by the provider to identify which social service or community resource is needed (a food bank, shelter, etc.). Before the patient even leaves the office, they can schedule an appointment with that service or resource, and, if needed, also schedule the transportation to and from that appointment. If follow up care with a specialist is needed, the patient can schedule that appointment and the needed transportation to get there, all in one seamless workflow.

Patients not only know where to go and when, but the digitized process helps providers track that part of the individual’s care history, allowing them to better serve that individual long-term. Also, by utilizing a digital platform, the burden is lifted off of the provider to record the social determinants and arrange for follow up. In this way, social determinants can be addressed like never before, enabling stronger, more robust connections between a patient and all the resources they need to be healthy.

Rather than rely on individuals to find and follow up with those resources on their own, many of whom are in underserved and vulnerable populations who just don’t feel empowered to take action by themselves, healthcare organizations can be an active partner in connecting patients to the right community resources, all without placing undue burden on the physicians.