How Are Leaders in the Trenches Strategizing around SDOH?

July 11, 2023

The emergence of work around the social determinants of Health (“SDOH”) has advanced very rapidly in just a few short years, as the leaders of patient care organizations nationwide begin to create the architectures necessary to determine the SDOH-related needs of their patients, and collaborate with health plans and with community service organizations to improve the health status of patients in lasting, deep ways unavailable in purely clinical settings. Leading off Healthcare Innovation’s recent Executive Exchange, held on May 9 at the Ritz-Carlton Tysons Corner in the Washington, D.C. suburb of McLean, Virginia, was a panel entitled “The Social Determinants of Health and the Path Forward in Population Health Management.”

Healthcare Innovation Editor-in-Chief Mark Hagland led a distinguished panel of experts and leaders in that key area:  Bryan O. Buckley, DrPH, M.P.H., director of health equity initiatives at the Washington, D.C.-based NCQA (National Committee for Quality Assurance); Tina Simmons, R.N., director of population health at Atlantic General Hospital (Berlin, Md.); Andrea Boudreaux, Psy.D., executive director at Children's National Hospital (Washington, D.C.); and Lauren Riplinger, J.D., chief public policy and impact officer at the Chicago-based American Health Information Management Association (AHIMA).

Early on in the discussion, Hagland asked the panelists how they were looking at social determinants of health (SDOH) issues, in the policy context. Bryan Buckley noted that “We’re looking at a macro level at all of this. We’ve been looking at our HEDIS measures and really looking at things also from a policy perspective, as well as from a research and policy perspective. From a measurement perspective, we’ve been evolving forward our universal foundation of measures, and about 70 percent of our measures are in there, including our social needs screening tool, which includes transportation, housing, and food issues, the three areas we’re really focused on. We launched our Health Equity Accreditation Program this year, for health plans, healthcare delivery, FQHCs; and our Health Equity Accreditation Plus Program looks at interoperability what data exchange with community-based organizations looks like, and how to make information actionable. We’ve also been doing a lot of research around community health workers, and how we might still leveraging them.”

“I’m so glad that NCQA is helping to push everything forward,” Hagland replied. “Plans, providers, all want that clarity” in terms of reward systems for work on the social determinants of health.”

And the challenges are many, including transportation, Hagland noted. “Tell us about transportation-related issues in your geographic area, Tina?” he asked Simmons. “We function across a tri-county area, with a lot of our partners and health systems,” Simmons replied. “Atlantic Hospital is at the southern end of Worcester County, which is very rural. It can take over an hour for someone to get to a hospital facility; that’s where a lot of transportation issues arise. From a health equity standpoint, that’s also where a lot of issues arise; a lot of vulnerable populations live there. We very much partner with our community organizations and with other local hospital systems. And we are trying to take care to patients; we recognize that a lot of patients aren’t going to be able to come to us; we need to come to them. That’s where we’re leveraging telehealth as much as possible; though you also have device- and WiFi-related issues there that you have to work through. But we’re trying to take as many services as possible into communities. And we’re working with our school; we developed a telehealth program with our school, but put it on hold because there were able to find local providers and create wellness centers. But we’re using technology that allows for a complete visual assessment if you connect providers to nurses. So we’re looking to deploy those teams to areas of the county where people can’t easily reach services; that’s a big area of focus. And also leveraging telehealth and behavioral health. We opened two crisis centers last year, with a group of almost 20 partners, grant-funded, but really embedding telehealth in behavioral health.”

“Andrea, how does this landscape look to you in Washington, D.C.?” Hagland asked Boudreaux, who said, “it’s amazing how we have such similar strategies in Washington, D.C. We, too, have been focusing on telemedicine; we, too, have been struggling with transportation issues. “The District is broken up into eight wards, and wards seven and eight are east of the [Potomac] River; and the life expectancy in Ward seven is 54 years, and in eight is 84 years. And at the crux of health equity is identifying the means to provide patients equal access to care. So what things do I need to put in place? That’s where health equity comes in. We work with the Foundation to get Uber rides; the District has added transportation to and from school into its budget. We, too, use telemedicine, and give children access to healthcare through school nurses. And we’ve already started our weekend mobile units going out into the community every weekend. We’re identifying how we bring care to people when and how they need it, to meet their needs, while addressing all the issues—food, transportation, and so on.”

“And Lauren and Brian, what are the biggest challenges in data, and what are we finding out? Bryan, why don’t you start on that topic?

“We actually came out with a paper last year that was supported by the Commonwealth Foundation. And we found that inputted versus self-reported data made a difference. We looked at all the data sources involved, and looked at accuracy,” Buckley said. “People want to understand how the data is collected, and whether they can trust it. So we believe that you really have to create a governance structure; governance is a key piece in all of this. But also, there’s this belief that patients don’t trust us. So we want to make sure that we’re seen as trustworthy. I teach at Georgetown University, and people tell me, go take a walk and see what people’s experiences actually are. And when you start doing more of that demo-walking, you realize how difficult it can be to collect that data.”

“I can imagine you have two faces to this,” Hagland said. “You want to protect patients and protect their data, but at the same time, we have to share data in order to improve the healthcare system.”

“That’s it exactly,” Riplinger said. “The question is, what are the challenges involved in the collection, sharing, and use of this data? In doing a nationwide survey of health information professionals, we found three top challenges around collection: training, organizational policy within their organizations, and patient mistrust. Lack of a trained workforce is a huge challenge. But also, a medical coder might not have access to the appropriate part of the record that would provide that kind of information. And where do I draw the line on this, as a medical coder? And really also, data is also not collected in initial intake processes. And providers don’t really want to be held accountable for collecting such data.”

“Bryan, could you share with the audience what The Gravity Project is, and how it might help?” Hagland asked. “We are involved in the Gravity Project, especially around our social needs measure. It creates alignment, and that’s pretty important in healthcare; and the Gravity Project involves the coding and interoperability level. And we do have a representative involved in the initiative. And I do think it will help, yes. The harder part is the funding and the implementation, and how we look at use cases in taxonomy. But it’s helping us all to start the conversation. Nothing is perfect, so let’s not let the perfect be the energy of the good. Let’s really all go in one direction, together.”

“Andrea and Tina, do you have any thoughts about the broad, policy-level issues that Bryan and Lauren have just referenced?”

“The challenge is where you get your data,” Boudreaux emphasized. “The challenge is that piece of where you can share data. The primary care clinic, the school, the hospital, etc. The data-sharing really helps us. We’ve looked at, how can we say, it’s my case management call, but we’re sharing it with all our partners? There are children in the school district who do not get care at Children’s National; and my job is to ensure that they have access to that quality care as well. So we’ve established a partnership with Howard University Hospital; and we’ve established a partnership with some of our local FQHCs [federally qualified health centers] in the area, to ensure that when we identify a need, we’re applying the resources, and getting those children connected. So, pulling that information and understanding that need, is critical; and then it’s critical to set local policies and institutional practice, around what we’re learning. Our chief diversity officer, who is phenomenal, says, we’re a data-driven practice. And when we collect data and don’t do anything with it, we’re missing making some connections. What we do with the data makes sure is critical to make sure we’re seeing better outcomes.”

“I agree with everything that Andrea just said,” Simmons said. “The data-sharing can be a huge barrier; you really want to coordinate care, and focus on the continuum of care. That’s one of the things we’re working very hard on, setting up processes for data-sharing with all of our community partners. From a broader perspective, any policy-level support will make it easier for us. We created our social-determinants screening tool and refined it; our first error we made was that we created drop-down options with yes/no answers. And our coders told us we were missing so much.”

“Where will we be as a healthcare system, about five years from now?” Hagland asked. “I am very committed to improving care; I’m hopeful that we’ll continue to transform our reimbursement models,” Boudreaux said. “I’ve just completed my tenure with the Healthcare Transformation Task Force, an organization focused on transitions; all of our members have committed to value-based care delivery—large payers, providers. It’s the way we’re going to change healthcare. Our system pays providers to see you when you’re sick; we don’t focus on wellness; we don’t have enough wellness-driven provisions in our payment system. My hope is that we will continue to move forward to reward wellness.”

“And a part of that will involve collecting and sharing data, correct?” Hagland said. “Per that, there was an interesting project at Michigan Health in Ann Arbor a few years ago. They had already been creating heatmaps around care delivery and wellness issues, and were already working at the zip code level; but a data analyst came and spoke to us about how you have to go even more granular, below the zip code level, to look at the health status of populations.”

“I think the current administration is going to continue to prioritize the collection and use of this data; and I think that future administrations will do so as well,” Riplinger said. “Value-based care models will increasingly emphasize the collection of SDOH data, and its use. CMS [the Centers for Medicare and Medicaid Services] is making it clear that they want to prioritize SDOH. But what keeps me up at night, and everyone has already referenced this, is that we can’t just have a goal of just data collection. Providers, nurses, case workers, all need to integrate this data into their work. We have to think about how we collect the data and then really apply it to care delivery.”

“We talk about being data-driven, but I want to remind us that while a lot of our conversation has been around quantitative data, there’s a lot of qualitative data in communities that can be utilized,” Buckley noted. “And that data is just as valuable for providing context, So you need to be talking to your community leaders, your faith-based leaders; they could have told you about the characteristics of specific neighborhoods; we need to always focus on people. Let’s make sure we’re diversifying the groups of people we’re talking to. One of the organizations that NCQA has just become involved in is the Rise Up Health Coalition. And we want to make sure we keep health equity in mind. And we need to think about our public health infrastructure, and getting public health involved. We also need to rethink our processes. How are we processing, and whom is our process privileging? Whom are we centering on—the organization or the people? And let’s focus on people. I always tell people to start somewhere. And what’s the story we’re going to tell ourselves, and our communities, about how we addressed health inequities?”        

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