Data Necessary to Appropriately Address Social Determinants of Health

The first panel of The American Journal of Managed Care^®’s Accountable Care Delivery Congress focused on new ways of delivering care to address social determinants of health. Rachel Gold, PhD, MPH, Kaiser Permanente Center for Health Research and OCHIN, explained that the biggest challenge to addressing social determinants of health that she is trying to overcome is helping community health centers start to collect social determinant data and document it so providers can actually be aware of them.

Developing care plans for patients is a futile effort if providers don’t know the patient’s social needs. For instance, if a patient is homeless, a provider shouldn’t prescribe a medication that needs to be refrigerated, she explained. The provider will need to change the care plan.

“Sounds obvious, but if the provider doesn’t know the patient’s homeless because it’s not in the record and they didn’t think to ask, then they’re going to create a serious barrier to the patient acting on their care recommendations,” Gold said.

She added that her research has also shown that sometimes there are reasons to not screen for social needs since sometimes the providers don’t have a way to address the patient’s needs. In the Portland area there is a housing crisis, so if a provider finds out that a patient is homeless, the provider might not actually be able to do anything about it.

Karin VanZant, CareSource, pushed back a little and emphasized that identification of social needs has to happen. There are always resources available even if certain geographic areas may have supply and demand issues. The trick is to knit together the social fabric and safety net within the geography, she said.

Carter Wilson, MCOM, Camden Coalition of Healthcare Providers, added that providers need to tailor screening questions to the available resources within a community. Still, he finds that primary care physicians are hesitant to ask questions about social needs because they don’t want to open that “can of worms.” He’s trying to train them to be comfortable bringing these issues up.

“It’s only a can of worms for the provider—not for the patient,” Wilson said. “The patient is living this life. They’re not traumatized by their own life or talking about their own life. So, it’s provider anxiety about what they’re going to do to their patients and it’s incorrect.”

In general, the Camden Coalition is operating in a challenging environment, he explained. Camden, New Jersey, is a “struggling city” where 69% of the residents are on Medicaid. The city is consistently ranked either first, second, or third as the poorest and most violent city in the country.

Across all professions, not just healthcare, people are trained in a certain way and to stay in the lane, VanZant said. Healthcare is now realizing that it needs to train across disciplines. She added that it’s important to realize they won’t always have the answers, but those questions still need to be asked in order for the right data to be collected so complete care plans can be created.

She explained how CareSource is working with prisons in Ohio to help incarcerated Medicaid-eligible individuals who have behavioral or mental health issues or substance use disorder, pick a plan, get supportive housing when they get out of prison, and transition successfully back into society.

CareSource then follows these people for 2 years and captures health and economic data. The recidivism rate for these individuals is just 2% compared with the average in Ohio, which is above 30%. It’s not necessarily a big return on investment (ROI) for the health system, but it’s a big ROI for the community, she said.

“When we think about where the ROI is coming from, it can’t just be the healthcare sector only,” VanZant said. “We have to look comprehensively across [the board].”

For Gold, the important question for the field of addressing social determinants of health is “How do we close the loop?” How do providers make referrals to social services and have something in place that informs the social service agency that the referral was made from the clinic and allows the agency to inform the clinic that the patient did or did not show up?

The data exchange is critical, but no one has really figured out how to do it on a large scale, she said. The data are also needed to figure out what interventions are working and are having an impact on outcomes.

What the field really needs now, Wilson said, is for people to publish the results of their pilots and studies on efforts to address social determinants of health. Gold and VanZant agreed heartily that more people need to speak up about what they’re doing.

“Regardless of whether or not you think your results are significant, put it out there,” Wilson said. “Don’t be embarrassed—the field needs it.”