SDOH Explorer, a tool developed by Innovaccer, is being used by CareAbout to analyze and monitor the impacts of social determinants of health (SDOH) on patients. It integrates SDOH data into patient records and workflows, providing customized dashboards to improve health equity. Clinicians can integrate SDOH data into clinical workflows and patient data through digital tools, ensuring seamless access and streamlined communication. Access to socioeconomic factors has enhanced organizations’ ability to address care gaps through coordinated workflows, advanced analytics, SDOH trend tracking, and scalable initiatives.
Health outcomes are influenced by factors that extend beyond traditional healthcare settings. However, the effective capture and utilization of social determinants of health (SDOH) data through analytics tools can empower providers to advance health equity.
Mohamed Humaidi, a healthcare data expert and Senior Vice President of Data and Analytics at CareAbout, a health coordination company based in New York and Florida, explains how clinical practices and health systems can improve and streamline the complex processes involved in identifying and reaching vulnerable patients. CareAbout is leveraging a new tool called SDOH Explorer, developed by Innovaccer, a vendor specializing in health data platforms, to assist healthcare stakeholders in analyzing, comparing, and monitoring the impacts of SDOH on patients.
Kanav Hasija, Chief Product Officer and Co-founder of Innovaccer highlights the customized dashboards of SDOH Explorer that reveal areas where health equity can be improved, benchmarking users’ performance on a national scale. The tool, rebranded as the County Health Report Card seamlessly integrates SDOH data into patient records and workflows.
Hasija and Humaidi also acknowledge the daily challenges faced by health systems in addressing health equity and how innovative healthcare technologies like SDOH Explorer can help overcome them. These challenges include a lack of standardized SDOH metrics, inconsistent data and measurement practices, inaccurate risk prediction for individual patients, inadequate screening tools for tracking SDOH, and the failure to consider SDOH when calculating risk.
One of the main hurdles is that health systems typically lack a single platform for managing social referrals, making it challenging to collect data at the point of care due to clinical responsibilities. SDOH screening can also burden providers digitally during appointments. Electronic health records, while crucial, cannot often integrate or exchange data easily, even among EHRs from the same vendor.
To address these challenges and effectively meet the SDOH-related needs of patients, CareAbout has collaborated with Innovaccer. This collaboration exemplifies cross-sector coordination and aims to integrate a data layer that assists organizations in addressing SDOH challenges and promoting health equity.
Q: How can accountable care organizations and value-based care organizations use SDOH Explorer at the county level to understand patients’ needs and challenges?
Humaidi: To illustrate the impact of such tools, let me share an example from my experience. From 2015 to 2017, I was involved in the Home Health Outreach Program in New York, specifically targeting Medicaid beneficiaries.
In this program, a Health Home, consisting of a collaborative group of healthcare providers, worked together to ensure patients received the necessary care and services to maintain good health. Each enrolled patient was assigned a care manager who helped develop personalized care plans, aligning services to improve their well-being.
Our program focused on enhancing the process of identifying and stratifying vulnerable patients, to enroll them in suitable programs. By providing targeted interventions and services, we effectively supported the most vulnerable individuals. Throughout the program, we achieved a 15% improvement in outreach performance from 2015 to 2016, and an additional 8% improvement from 2016 to 2017.
By leveraging a tool like SDOH Explorer, the impact of such initiatives can be significantly multiplied. County-level data empowers healthcare providers with a detailed understanding of social determinants, facilitating better identification and documentation of SDOH insights within specific populations. This, in turn, enables more informed decision-making and improved outcomes for patients.
Q: How do clinicians integrate SDOH data into clinical workflows and patient data to improve care access?
Humaidi: Clinicians can integrate SDOH data into their clinical workflows and patient data to improve care access through various methods.
Firstly, they can embed SDOH assessments within the digital tools commonly used during in-patient encounters. This streamlines the process of collecting relevant SDOH information directly within the existing workflow.
Additionally, clinicians can send assessments to patients via email or text, allowing for the collection of SDOH data outside of the clinical setting. Once collected, this information can be seamlessly integrated back into the patient’s electronic health records (EHRs), eliminating separate data silos and ensuring that relevant data is readily available within the patient charts.
To further enhance the integration of SDOH data, healthcare organizations can leverage healthcare-contextualized digital tools. These tools can write back the collected SDOH data directly to native EHRs, ensuring easy accessibility and eliminating the need for manual data entry or data transfer between systems. Such tools can also generate insights from SDOH data, providing anytime-anywhere access to valuable information.
Furthermore, establishing centralized coordination between primary care providers, community-based organizations, and social services is crucial. This coordination helps effectively close referral loops and maintain transparency in addressing patients’ needs. It enables a seamless flow of information and resources between different stakeholders, leading to improved care access.
To ensure the effectiveness of community-based organizations (CBOs) in meeting patients’ needs, healthcare organizations can track their engagement and establish incentive models. This encourages a proactive and responsive CBO network, contributing to better care access and outcomes for patients.
By leveraging a data and analytics platform with prebuilt integrations with leading health IT systems and vendors, healthcare organizations can clean, standardize, and unify all healthcare data sources, including clinical, claims, labs, pharmacy, SDOH, and device data.
Having a centralized and unified platform enables improved collaboration, native interoperability, and accelerated innovation in care delivery. This approach provides a scalable foundation for leveraging SDOH data and improving care access in a sustainable and future-proof manner.
Q: How has access to socioeconomic factors such as housing, food, transportation, and social connectedness improved the organization’s ability to address gaps in care?
Humaidi: Access to socioeconomic factors such as housing, food, transportation, and social connectedness has significantly enhanced organizations’ ability to address gaps in care. Several key factors contribute to this improvement:
1. Coordinated workflows: By utilizing interoperable technology, organizations can establish streamlined and transparent communication channels between network providers, patients, and community-based organizations (CBOs). This facilitates seamless collaboration and enables the fulfillment of patients’ needs.
2. Advanced predictive analytics: Leveraging sophisticated analytics tools allows organizations to generate valuable insights into patient care. These insights can be used to improve outcomes, manage high-risk populations, drive cost savings, and foster stronger relationships with patients.
3. Tracking SDOH trends: Organizations can monitor and analyze SDOH trends across the community. This helps identify areas of need and measure the impact of interventions by providing detailed insights on screenings and referral outcomes.
4. Scaling initiatives: By leveraging data-rich insights, organizations can scale initiatives from a subset of patients to broader populations within a region. Geo-targeted interventions guided by these insights enable targeted support and resources where they are most needed.
In the case of the Health Home Program, we utilized socioeconomic data to optimize outreach and clinical operations. By understanding the specific socioeconomic factors affecting each patient, we created tailored daily call lists and assigned the appropriate health home care coordinators. This led to improved reconciliation and billing processes, benefiting our patients. Thanks to these insights, we were able to provide services to approximately 88% of the patient population, addressing gaps in care more effectively.
