While we know that outcomes can be materially impacted by non-clinical factors like social determinants of health, the industry’s strong focus on medical factors have long pushed social determinants to the backseat. It is clear that population health management is most effective when it is comprehensive and community-based, extending beyond the walls of a single care establishment to encompass all relevant services, including medical, behavioral, and socioeconomic factors. But what will truly make a difference to patients is being able to prescribe how to address the social determinants in a normalized manner that will consistently improve patient outcomes.
As an organization transitions to value-based care and makes decisions on the interventions and level of intensity needed to address a patient’s social determinants of care, the ability to measure results—and draw insights from those results that can be used to improve outcomes—is critical. What will truly put social determinants onto the map is developing evidence-based care in the social realm—with the same rigor of common terminology, infrastructure to manage and move information, and prescribed workflow based on an accepted body of knowledge that supports demonstrable and repeatable success.
Elevating the importance social determinants of health is difficult. The environment is very complex, with many types of disparate organizations that need to be coordinated to improve the physical health of patients. Common tools that capture descriptions of social factors and the protocols and interventions that address them do not exist, making it difficult to find a common language to develop a shared body of knowledge. Without a clear path to payment, there is little incentive for organizations to push forward. And because social determinants vary from region to region, the best practices of one organization may not transfer to others.
So is it a big enough factor to be important? The answer is a resounding yes. And it matters even more in today’s healthcare environment as organizations across the nation shift to value-based care.
Value-based care involves connecting a variety of different medical encounters in a protocol that should successfully treat a condition. But what it doesn’t take into account is that every time a patient leaves the controlled environment of a medical provider, they enter a social context that has to be dealt with. It’s within this social context that social determinants of health come into play. We need to be able to bridge the gap between the medical and social realms to get patients to where they need to be.
To get there, we need a care model that goes beyond the reactive management of care—simply healing people who are sick—to a proactive model that helps prevent people from getting sick. This approach requires providers to understand the patient outside the medical office—and be able to address their social issues using partnerships within the community that help keep the patient on track. By creating a community-based care plan that connects medical, behavioral, and social service providers, we can coordinate what we are going to do for a patient in the future—plus give everyone a say in how we do it together so we can harmonize our efforts.
Drawing information from the interdisciplinary team, we’ll not only have insight into what determines health, the factors that are involved, and what to do about it, but develop interventions that can be applied across the interdisciplinary care team to the broader population. Over time, providers can normalize what actions are being taken, measure results, validate care steps, and build models that determine efficacy. This will lead to an empirical set of evidence-based activities for social determinants of care that can be prescribed at the point of care. The end result will be more efficient and effective collaboration with a measurable reduction in admissions and emergency department usage.
The shift to value-based care and population health management is an opportunity for all of us together to raise the awareness of social determinants of health, and promote the care planning, coordinated care teams, and common tools that will enable providers to treat the whole person instead just medical conditions. Laying a foundation that is empirically based will pave the way to make true progress toward evidence-based care for social determinants of health.