In recent years, social determinants of health (SDoH) have increasingly become a central topic of discussion among healthcare professionals and policymakers. These determinants encompass a broad range of social and environmental factors that affect individual and community well-being. But understanding their impact is not just about identifying what they are; it is about using data and health analytics to gain insights that can lead to better health outcomes for populations.
Effective population health initiatives have the potential to improve health outcomes, promote health equity and reduce rising healthcare costs.
For example, recent studies reveal that 84% of pregnancy-related deaths are preventable, with cardiovascular conditions being the leading cause among women overall. Notably, Black and AIAN (American Indian and Alaska Native) women face significantly higher mortality rates, approximately two to three times that of white women, underscoring the critical need for targeted healthcare interventions.1
The approaches that organizations take when addressing SDoH are as varied as the communities they aim to serve. Strategies addressing SDoH range from tackling broad community health disparities to preventing specific health conditions linked to socioeconomic circumstances and lifestyle factors. However, all these strategies start with the fundamental task of gathering accurate and relevant data. Examples include:
- Integrating SDoH into clinical care: Clinicians are beginning to incorporate SDoH data into their patient assessments and care plans. Health analytics can facilitate this integration by identifying relevant social determinants for each patient and suggesting appropriate proactive interventions, such as patient outreach and communication, social risk screening, and referrals as needed to community-based resources or social services supports. Some organizations are developing and testing instruments to detect and measure patient-reported challenges with determinants, such as housing, transportation, and nutrition.
- Improving population health management: Population health management focuses on improving health outcomes for a group of individuals. Analytics can help identify which social determinants are most influential for different populations, enabling healthcare organizations to tailor their programs and services to address these factors effectively.
- Enhancing community partnerships: Health analytics can help healthcare organizations identify potential community partners who share similar goals for addressing social determinants. By leveraging data insights, organizations can form strategic partnerships that enhance the reach and impact of health interventions.
With health analytics, there is a greater capacity to analyze and act upon the data related to SDoH.
Addressing SDoH disparities: Strategies for change
Healthcare organizations increasingly recognize the importance of addressing social determinants in their efforts to provide high-quality, equitable care. Data insights gained through health analytics are key to these efforts. By integrating and analyzing data from diverse sources, such as electronic health records, census data, and patient surveys, healthcare organizations can gain a holistic understanding of the factors that contribute to health outcomes.
Here are three examples of payer organizations that have leveraged Milliman MedInsight (MedInsight) solutions to drive innovative solutions for improving the access, quality and cost-effectiveness of healthcare.
1. Creating a “culture of health equity”
CalPERS, which provides health coverage for California state employees, implemented a health equity initiative that began with a demographic survey in which members self-reported data related to race, ethnicity, language, sexual orientation, and gender identification. Gift cards were provided to boost participation. When combined with information culled from the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), the member-provided information helped to create a much more nuanced and tailored picture of the population.
The data underpins a larger effort to create an internal “culture of health equity” across the healthcare network, including seven insurance carriers and a dozen plans which underwent significant changes to advance health equity. Among other requirements, each plan is now required to have a chief health equity officer, to approach benefit options from a “health equity lens” and to stratify clinical quality measures by SDoH criteria.
2. “Neighborhood Stress Scores” & population health
MassHealth, which provides health benefits to Massachusetts Medicaid and children’s health insurance program members, utilized a proprietary SDoH risk adjustment model2 to measure and account for hardships at a neighborhood level, with criteria that included community design, environmental exposures, education and employment levels, housing, social environment factors and exposure to violence3.
By identifying the chronic conditions and health patterns across its membership and implementing outreach strategies that included preventive care, diet and exercise initiatives, telehealth, mental health and 24-hour nurse line access, the department was able to reduce Emergency Department visits by 15% while improving patient outcome and satisfaction.
3. Identifying healthcare barriers
An employer that wanted to understand the social determinants preventing some members from getting needed healthcare sought analytics to determine what was causing the care gaps.
Combining state level data with MedInsight Health Cost Guidelines Groupers and Chronic Conditions Hierarchical Groups (CCHGs), the organization was able to identify gaps around language barriers and other social determinants. The findings sparked an outreach effort and an initiative to put mobile clinics in parts of the community.
Tools & analytics for population health insights that drive change
While these are a just a few from among many examples of ongoing SDoH and health equity initiatives, the effort to fully incorporate socioeconomic hardships into the equation for lowering costs and improving healthcare quality has far to go, and many as-yet undiscovered innovations to bring forth.
At MedInsight, we understand the impact of social determinants on health is crucial for creating a more equitable healthcare system. Through the power of our health analytics, healthcare organizations can use data insights to inform strategies that address these determinants, improve patient care, and ultimately enhance community health.
Watch the webinar
Discover how healthcare organizations are enhancing healthcare outcomes by addressing the root causes that impact communities by watching the webinar titled “Strategic Approaches to Social Determinants of Health: Prioritizing Impactful Data for Population Health.” Gain insights from Milliman MedInsight and CalPERS as they share best practices to optimize population health initiatives.
Speak with one of our healthcare analytics team members to learn more about how we can help accelerate your health equity efforts.
References:
1. Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them | KFF
2. MassHealth Risk Adjustment Methodology | Mass.gov
3. Paying for Medical and Social Complexity in Massachusetts Medicaid | JAMA Network.com