It was an honor and a pleasure for me to moderate several very important panel discussions last week, Wednesday, July 14 and Thursday July 15, during our Rocky Mountain Healthcare Innovation Summit, held at the Grand Hyatt in downtown Denver. Our panel discussions ranged very widely from the important developments leading more provider organizations to take on two-sided risk in value-based contracting to the challenges and opportunities facing health information exchanges (HIEs), to the complexities of moving forward on EHR [electronic health record] optimization at a time of intense needs on the part of clinician end-users in patient care organizations. And we had the opportunity to introduce our gathered audience to two of the leaders of our Innovator Awards Program first-place-winning team from the locally based UCHealth; that team has done an amazing job in creating a series of virtual health centers to support patient care delivery at that integrated health system’s community hospitals, and building on that foundation to leverage predictive analytics to be able to intervene earlier in emergent cases of sepsis. There was so very much to talk about at our Rocky Mountain Summit, attendees told us that they were pleased and impressed what all that was shared.
One panel that was of especial significance in the current operating environment of U.S. healthcare, I found, was our panel “Utilizing Social Determinants of Health Data and Other Unique Data Sources to Improve Care, held on Thursday morning. We were blessed to have an absolutely top-level group of leaders from across the healthcare stakeholder landscape of Colorado, namely, Kirsti Klaverkamp, program manager at the Colorado Health Institute; Stephanie Bennett, state health IT coordinator in the Lieutenant Governor’s Office of eHealth Innovation; Al Diamantopoulos, manager of accountable health communities at the Denver Regional Council of Governments; Lindsay Reeves, director of Early Childhood Programs at the Catholic Charities Diocese of Pueblo; and Gail Abeyta, director of care management at Parkview Medical Center in Pueblo.
Not only did each panelist represent a different stakeholder organization in the constellation of public health in the state of Colorado; every panelist shared extremely important insights with our assembled audience.
AJ Diamantopoulos, early on, noted that there are two terms that are also concepts, that should be understood separately and distinctly from each other—that is to say, social determinants of health (SDOH) and health-related social needs. As he explained it, the social determinants of health are the broad factors impacted populations, including hunger and food insecurity, homelessness and near-homelessness, lack of transportation, and other factors that influence how people access and use healthcare and social services; meanwhile, health-related social needs are the more immediate factors impacting what individuals do and can do on a moment-to-moment basis—for example, without access to transportation, a patient might well not show up for their follow-up appointment for primary care and care management following a hospitalization. Similarly, an individual lacking any housing stability will find it very difficult to regularly fill their prescriptions to keep their chronic illness or illnesses under control. Without stable living conditions, it is obviously very difficult for a diabetic to maintain good glucose control; the same thing goes for a person with congestive heart failure or with hypertension. And what about the sincere attempts of provider leaders to help to care-manage patients with chronic diseases through using online tools and platforms? The lack of broadband access in rural areas remains a daunting barrier for many rural residents nationwide.
What’s more, as Thursday’s panelists agreed, the landscape on the ground remains extremely fragmented and even confusing, in terms of care managers and social workers in patient care organizations effectively connecting patients to community-based social services. Even documenting SDOH elements into any patient’s EHR remains exceptionally difficult, as we still lack any standards for developing code sets—indeed, any standardized vocabulary—for effectively documenting any SDOH or social needs factors in patients’ charts.
And then, one level up, the connections between both patient care organizations and non-governmental organizations (NGOs) and state health agencies, remain largely unorganized right now in Colorado as well as in other states. The good news? Colorado is in the vanguard of state governments that are attempting to begin to connect all these different “dots.”
In that regard, it was wonderful to have Colorado Lieutenant Governor Dianne Primavera give a keynote address following the conclusion of the SDOH panel discussion. Lieut. Gov. Primavera, who worked for years as a patient advocate before becoming Lieutenant Governor, noted a number of recent accomplishments of the administration headed by Gov. Jared Polis and herself, that were spearheaded in the Colorado Legislature, including Gov. Polis’s signing on June 27 of Senate Bill 60, which provides financial support for access to broadband; Gov. Polis’s signing on June 28 of House Bill 1289, which provides $35 million in funding to support grants for broadband deployment statewide; and House Bill 1109, which the Governor signed on July 7, and which directs the state’s broadband deployment board to develop a plan to deploy broadband across all the critically underserved areas of the state. As Primavera noted on Thursday morning, large areas of Colorado remain tremendously underserved in terms of broadband access.
As all the panelists agreed on Thursday morning, creating all the connections needed to improve the health status of all Coloradans, or for that matter, the residents of all the states in this country, remains a hugely daunting challenge. Just creating some kind of standardized language with which all the stakeholders can document and share SDOH data remains an immense challenge, they agreed. Stephanie Bennett made the point that it will be impossible to impose some kind of nationwide terminology standard on the vast range of patient care organizations, community service organizations, NGOs, and state government agencies.
Meanwhile, down on the ground, Gail Abeyta noted that she and her colleagues have been making progress at Parkview Medical Center in Pueblo. Abeyta noted some of the challenges that she and her colleagues had been experiencing as they worked to complete meaningful patient assessments around social needs, but also how bringing in community-based social workers to educate the team members performing the assessments, around available community-based social services to which to refer patients, made all the difference.
Towards the close of the panel, I made the observation that the landscape around the social determinants of health and health-related social needs, right now in 2021, reminds me of the landscape around population health management and care management ten to fifteen years ago. As with SDOH, back then, patient care leaders were somewhat daunted by the vast range of challenges involved in creating organized systems of activity around population health management, which was in its infancy a decade and a half ago. What happened subsequently was that the pioneering organizations in the population health management and care management arena, through initial hard work and experience, in effect created templates for others across the healthcare system to follow. I said that I believe that the same kind of phenomenon will occur with regard to trans-stakeholder cooperation around the social determinants of health and health-related social needs, and my fellow panelists agreed.
So, ultimately, there is a very, very broad frame around all of this, and it is societal. There are huge policy issues involved in this area; but the good news is that leaders from all the stakeholder groups across the constellation of healthcare, community, and public policy entities in Colorado, are already moving forward to create a new reality, one that will improve the health of not only Coloradans, but potentially residents of other states as well. We just need to keep moving this train forward.
