Where Are Health Systems Falling Short in Addressing Social Determinants of Health?

July 28, 2017
Eighty percent of executives surveyed by the Deloitte Center for Health Solutions said social needs are a core part of their mission, but 72 percent said they don’t have sustainable funding to do it.

One trend I have been eager to follow over the past few years is the emergence of a focus on social determinants of health and data sharing across sectors. I wrote about it as one of our Top 10 Tech Trends this year, and I noted that it was a highlight of several presentations at the Health Datapalooza conference in 2017.

So I was intrigued that the Deloitte Center for Health Solutions recently surveyed and did follow-up interviews with hospital officials about their efforts to gather and analyze social data about their patients. Their survey of 284 U.S. hospitals found that while health system goals are shifting toward social needs and clinical care alignment, hospitals have a long way to go to if they are going to reap the benefits of coordinated care and evolving payment models.

I recently interviewed Josh Lee and Brian Doty, principals in the firm’s Healthcare Provider Strategy Practice, about the survey.

One of the surprising findings, Lee said, was that health systems were gathering data on social determinants largely in the acute-care and emergency department setting, but not in primary-care settings.

“We were both surprised and not surprised to find the acute-care setting and the high-utilizer population seem to be the ones getting the screening most consistently,” he said. “It is not surprising because that is how our U.S. healthcare system works. There is a disproportionate focus on the acute-care episode — people who are already in trouble and getting intensive services. Strategically, you would like to see the resources getting pushed the other way: early screening out in the community and getting people the kind of care they need before they get the acute episode.”

I asked Lee for an example of how hospitals might use social determinant information. He said patient connectivity is key. “We know that about 80 percent of healthcare outcomes are driven by activities that happen outside the official clinical system, so even just modest efforts on the part of the clinical enterprise to stay connected to patients, either in preventive fashion or in post-acute follow-up would be valuable,” he said. “There is an incredible breakdown once the patient leaves the boundaries of the clinical system.”

Doty said that social determinants make up just one aspect of the drive toward population health, and that other sources of data can help with predictive modeling and getting a better idea of who your high-risk patients are likely to be. “There is publicly available third-party data that can be paired with demographic data to understand things proactively, such as whether patients live in a food desert or whether they have access to public transportation,” he said. There is interest — but also anxiety — around leveraging things like social media to hone in proactively on behaviors and preferences that can give us clues to risk or prevalence of certain social determinants.”

I asked them if there should be a place in the EHR for social determinant data to be entered or alerts to be given to providers.

Doty said there is dome data that would lend itself to that, some can be taken in an interview on social history with the patient and entered into the EHR. “But it doesn’t have to reside in the EHR,” he said. “There may be opportunities to use some external analytics to feed that back into EHR in terms of alerts to ask questions or dive more deeply.”

The Deloitte report noted that “less than one-third of hospitals report integrating social needs into the EMR for most of their target population. One interviewee says that though the EMR has some valuable social needs data, much of it remains buried. Other interviewees note that this data often comes in the form of social work notes that the care team may not regularly access. Further integration of data into the EMR, and strategies for making this data more useful for the care team, may help hospitals in the future.”

Lee noted that funding for efforts to gather and understand social determinant data is scarce. There are three numbers in the report that stand out, he said: 80, 72 and 40.  “Eighty percent of the people we surveyed said, yes, social needs are a core part of our mission. Seventy-two percent said they don’t have sustainable funding to do it. That is in many ways a heartbreaking mismatch. They are saying ‘we know this should be part of our mission, but we really don’t know how we can pay for it.’ Forty percent felt they were doing something in this regard, but had no way of measuring whether it was working or not. Those three numbers tell the story.”

Another headline from their report, he said, is that there was a high correlation between health systems that were screening for social determinants and those that were involved in at-risk payment models and were already pretty far along in their journey to value-based care..

I asked if integrated health systems such as Kaiser, Partners Intermountain and Geisinger were more likely to be further down this path. Lee said yes. “Kaiser has invested heavily in this area,” he said. The Healthy Oakland Project is a Kaiser effort to raise the health status of the City of Oakland across the board. “They are pioneering a lot of the new approaches here, and Partners is also at the forefront.”

Doty said one of the biggest barriers to optimizing this work is the regulatory, privacy and risk environment with data sharing. “It is not a technology problem. It is all of the other issues associated with open data sharing that are going to be harder to overcome.”

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