Social Determinants of Health and the Importance of Patient-level Insights

August 4, 2017 Inovalon

To deliver patient-centered care and improve long-term health outcomes, healthcare organizations are increasingly investing in efforts to address patients’ social needs, such as housing, employment, education, transportation and family support, in addition to their clinical needs, according to a new study by the Deloitte Center for Health Solutions.

These social needs, often impacted by where a person is born and where he or she lives, works, learns and “plays,” are often referred to as social determinants of health — important environmental conditions have a direct correlation to health risks and outcomes.

According to the study, the healthcare industry’s shift to value-based care has contributed to the increased investment and activity surrounding the social determinants of health, noting that organizations “participating in value-based care models are more likely to measure all social needs activities, including health outcomes, cost outcomes and patient experience.”

Information on social needs has always been important to healthcare providers, but knowing and understanding what this information means for each individual patient is essential to providing the high-quality patient-centered care required under value-based care models. According to the Robert Wood Johnson Foundation’s County Health Rankings and Roadmaps, social determinants of health are accountable for as much as 50 percent of healthcare outcomes — more than actual medical determinants, such as health history.

Socioeconomic Data Offers Key Insights for Improving Outcomes

The Medicare Access and CHIP Reauthorization Act (MACRA) incentivize providers to help their patients improve their overall health and wellness and then help those patients maintain their health. Leveraging socioeconomic data to improve care quality and overall health outcomes, as well as to increase patients’ engagement in their own health, needs to be a standard element in physicians’ workflow, according to LexisNexis Health Care. And that means going beyond typical medical claims data.

Many early risk factors for chronic diseases and conditions can be unearthed in socioeconomic data. Although a patient’s medical history may not show a risk for developing heart disease, the social determinants of health may paint a different picture. Managing to those risk factors early can help prevent costly health interventions down the road. Likewise, once a patient is in the hospital, providers can (and should) use socioeconomic data when determining the post-acute care setting in which a patient is most likely to succeed, helping to lower readmission rates. Does a patient have someone to help them at home? Do they have the financial means to hire home healthcare? The answers to these questions are in that socioeconomic data.

Patient-specific Analytics Drive Patient-centered Care

Advanced analytics facilitate deeper patient-level insights and inform effective, targeted outreach to the right patient, through the right venue and at the right time, driving meaningful improvements in care quality and patient retention. When you couple socioeconomic data with electronic health records you receive a more complete picture of current and future health for a patient population. These predictive analytics thus enable more informed decision making about a specific patient’s care plan, producing better individual health outcomes while driving efficiencies and improving economic performance.

For more information about data-driven insights using population analytics, read a case study of how one healthcare organization successfully leveraged social determinant of health data to deliver patient-centered care and improve care coordination, quality outcomes and economic performance.

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