Care Transformation Center Blog

Here's how 4 organizations are leveraging IT to address social determinants of health


Editor's Note: This blog is a rebroadcast of Here's how 4 organizations are leveraging IT to address social determinants of health, originally posted by Andrew Rebhan and Peter Kilbridge.

On Tuesday, I shared a table outlining key social determinants of health to prioritize for population health programming. When it comes to program development, knowing where to focus is only half the battle—actually identifying patients in need is the other. IT plays a critical role for providers to manage social determinants of health in their patient populations.

How to leverage IT to manage social determinants

Here's how four leading organizations have leveraged IT to address social determinants:

Mission Health Partners (MHP)—This Medicare Shared Savings Program (MSSP) accountable care organization based in North Carolina has been partnering with local agencies to identify and close gaps in care created by socioeconomic factors. For instance, MHP partners with the analytics firm Lumeris to identify high-risk patients and predict which of those individuals would benefit the most from interventions. Rather than rely on claims and clinical data alone, their predictive modeling tool incorporates social determinants (e.g., housing, transportation, marital status, financial status), populates the data in the EHR, and—with that—allows the system to provide targeted social support for at-risk patients. Using this expanded set of data over a six-month period, MHP saw a 25% increase in the accuracy of its population risk predictions, greatly improving care coordination and reducing utilization.

Indiana University-Purdue University Indianapolis—Researchers at this public research university partnered with the Regenstrief Institute to develop algorithms that can predict the need for social service referrals at a safety-net health system in Indianapolis. Using data from 48 socioeconomic and public health indicators, the algorithm can predict the need for mental health support, dietician counseling, social work services, and other related services. Data sources for the models included the health system's EHR, order entry data, clinician notes, the local health information exchange, and public health data pulled from the US Census Bureau, community health surveys, and county vital statistics. While still a work in progress, results of a study showed that the predictive algorithms yielded specificity measures ranging between 60% and 77%, depending on the type of referral.

Humana—Social determinants have played a part in Humana's Bold Goal initiative to improve the health of its members 20% by 2020. The Bold Goal program has multiple areas of focus, including food insecurity and social isolation. Humana researchers discovered that people who are food insecure are 50% more likely to be diabetic and 60% more likely to experience heart failure. In a four-week screening and referral pilot study, Humana screened 369 members for food insecurity, and then offered Supplemental Nutrition Assistance Program (SNAP) benefits and emergency food boxes to those who qualified. As a result, the patients receiving food assistance saw the number of days they were either physically or mentally unhealthy cut in half.

NYU Langone Health—Partnering with the Robert Wood Johnson Foundation, the Department of Population Health at NYU Langone Health built the City Health Dashboard, a public online resource that provides interactive clinical and social determinants of health data for the 500 largest U.S. cities. The dashboard currently covers 36 measures of health split across five categories: social and economic factors, health behaviors, health outcomes, physical environment, and clinical care. With this tool, users can see which neighborhoods fare worse across different health outcomes within their city, and see what is contributing to those differences—they can also benchmark their city to others within the database. In addition, the City Health Dashboard site provides resources linking users to evidence-based policies and programs to address any health and wellbeing challenges they identified in their community.

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