Population Health Management

Improving Outcomes Using Social Determinants of Health

June 2, 2017 2:08 pm

As health care moves increasingly toward value-based payment models, pressure is mounting for healthcare providers to improve patient outcomes. New heightened levels of accountability are increasing the need to look beyond clinical data to improve patient care.

Providers have long recognized a connection between a patient’s health and social factors such as economic status, environment, and social support. Historically, socioeconomic data were not readily available beyond summarizations, but recent advances in data technology have made it possible for healthcare organizations to collect and analyze data and turn the data into insights that can guide the actions of medical personnel.

Uncovering Hidden Risks and Costs

Healthcare organizations traditionally have used medical and pharmacy claims data as main sources of patient information, but they would be well served by additional data to complete the picture. By using socioeconomic data to predict future health, an organization can obtain relevant information that can contribute to deeper and more thorough discussions between the providers and patients.

Studies show that social determinants of health account for as much as 50 percent of healthcare outcomes whereas medical determinants account for only 20 percent. The likelihood that a person might develop certain health conditions, and be unable to manage those conditions should they occur, depends largely on the social determinants of health affecting the person’s choices and actions around maintaining good health.

By being able to predict future health, an organization can expose hidden risks and costs that cannot be identified through traditional data sources.

What the Data Reveals

Socioeconomic data encompass variables such as education, income, housing, community involvement, neighborhood safety, and personal relationships. When used to augment clinical data, social determinants of health allow providers to more precisely identify health risks, especially for new patients who don’t have a medical records and claims history.

Data found in public records can show a correlation with health risks. Examples of different types of data and possible correlations with health status such data might indicate include the following.

Personal finances. Financial issues can cause great stress. They also can be the reason people put off physician visits and stop buying prescribed medication, potentially compromising their health.

Education. Lower levels of education are linked to lower health literacy, which can increase risk levels.

Voter registration. Individuals showing engagement in their community may be more likely to engage in maintaining their own health.

Law enforcement. Records pertaining to accident investigations could indicate future medical issues.

Derogatory records. Liens, evictions, and felonies may be indicators that a person does not prioritize health.

Practical Applications in Health Care

Social determinants of health can help healthcare practitioners focus on prevention. By being able to identify patients who are at risk for negative health events, practitioners can intervene and perhaps prevent the events from occurring.

Providers can reach out to patients and encourage them to make lifestyle changes that promote good health. For patients with chronic diseases, providers can offer guidance in managing their illness that works within their dynamic lives, potentially reducing severity. For patients recently released from the hospital, aftercare counseling could prevent complications and readmissions. The resultant savings in healthcare costs could be significant.

Integrating Social Determinants Into Value-Based Care

With an increasing emphasis on value in health care, providers now find their financial incentives and payment and incentives tied to the quality of care they deliver. Value-based models reward better outcomes and lower spending. 

Healthcare providers will need to closely track value measures such as complications, hospital-acquired infections, and readmissions. And they’ll have financial incentives to ensure their patients remain healthy by making good lifestyle choices and adhering to prescribed treatments.

Those organizations that improve health outcomes through the integration of social determinants of health into their workflow have the best prospects of flourishing in the new value-based landscape. 

Rick Ingraham is director, vertical markets for health care, Lexis Nexis Risk Solutions, Denver. 


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