The shift toward value-based care is forcing provider organizations to consider the impact of social determinants of health (SDH) on outcomes. In response to these forces, provider organizations must develop mechanisms to capture, analyze, and integrate these new data sources into clinical workflow. Incorporating SDH data into care management and delivery will determine providers’ effectiveness at managing the health of populations beyond the traditional care encounter.

In this report, we define SDH, outline a vision for connected care, evaluate different approaches to gathering SDH data, and give some initial considerations for how to approach SDH initiatives in your organization using IT.

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Introduction to SDH and Connected Care

We are entering an era in which patients can give clinicians data on their daily lives to provide a more complete, holistic picture of health. These new sources of data can help give clinicians greater insight into the periods between visits, opening a window onto how patients live at home, at work, or in the community.

• 1. Defining Social Determinants of Health (p. 7)
  2. Social Determinants Compound Systemic Barriers (p. 8)
  3. A Vision for Connected Care (p. 13)

SDH Sources and Use Cases

When it comes to sources and methods of gathering SDH data, there are a few options. Many health care providers simply ask their patients directly for this information. There are also public sources of SDH data, as well as vendor products. Lastly, health systems can leverage community partners for data capture.

• 4. Ask a Patient (p. 16)
  5. Use Third-Party Public Sources (p. 19)
  6. Use Private Company Solutions (p. 20)
  7. Work with Community Partners (p. 22)

Key Considerations and Next Steps for Using SDH Data

Apart from evaluating data capture options, health care organizations will need to plan for how to properly code SDH data so it can be leveraged as discrete data in EHRs, how to communicate SDH risk factors with patients, and how to develop effective coordination with referral partners.

• 8. A Conceptual Model for SDH in Primary Care (p. 31)
  9. Sample Measures for EHR Capture of SDH (p. 32)
  10. Partner for Sustainability and Efficacy (p. 34)

For details on each of the 10 steps, read the full report.

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