Starting small with SDOH data can lead to big outcomes


Jeff was a homeless, unemployed Medicaid recipient living in Arizona.* He suffered from chronic kidney disease, depression and a serious foot injury, and had frequent ER visits, hospital admissions and inpatient stays. His average monthly cost of care? $20,400.

He is one person out of a population of millions — at first glance, you may think Jeff’s impact on our health system is minimal. But the numbers add up quickly. After all, just 50 homeless, unemployed Arizonans like Jeff who have a similar average monthly cost of care add up to $1,020,000 per month for care. That’s an example of a costly burden on our health system, not to mention the poor health and quality of life suffered by the people themselves.

The idea of alleviating health inequities caused by social determinants of health (SDOH) can be overwhelming. There are some big, complex challenges to confront — not the least of which is where to start. In Jeff’s case, he lacks a safe space to rest and recuperate, he has difficulty purchasing food and medicine, and he likely has difficulty getting to follow-up appointments. For a local organization determined to help reduce these barriers to health, it could be tempting to try to tackle all of them at once. But before we begin to address social and behavioral factors impacting population health, we should start small — with thoughtful collaboration and careful planning.

  1. Break through silos to form — and accomplish — a shared vision

Realizing that we still have miles to go, care providers, health plans, employers and government agencies, along with their vendor partners, may find value walking alongside one another to bring about their shared goals and vision. Breaking through silos takes time and commitment — it’s a one-step-at-a-time proposition.

The Camden Coalition Health Information Exchange (HIE) in Camden, New Jersey, is one breakthrough example that comes to mind. This collaborative data-sharing effort was launched in 2010 to improve care delivery in Camden. Using web-based technology, the HIE joined together local, then regional, health care providers and partners to improve care coordination and identify citizens who are eligible to enroll in intervention programs.

From these local and regional “small steps,” the National Center for Complex Health and Social Needs launched in 2016. The Camden Coalition grew into a resource that works with organizations across the country to serve individuals with complex health and social needs in their communities.

Taking time to build a network — from hospitals to health insurers to social service organizations — that can respond to the findings of SDOH analytics can lead to big benefits. That is, protecting and improving lives.

  1. Be deliberate and patient

Before launching into an endless loop of data gathering, it’s vital to dig deep and stop long enough to let the small steps lead us to big questions and how to answer them. Today’s analytics can help you look beyond the numbers to ask questions about the situations and settings of families and communities to identify and prioritize what you’re trying to accomplish.

Artificial intelligence (AI) models can take the data you’ve collected and help predict which segments within your population may benefit from different programs. With this data-driven approach, you can gain greater confidence that you’re putting your limited resources to work where they can make the most difference.

Not everything needs to be — or should be — fast-tracked. It takes time to align across diverse participants. It’s the whole “it’s not a sprint, it’s a marathon” concept. So, join with fellow SDOH marathoners to embrace the process of first gathering data based on the plan and then getting a grasp on the answers and new questions that may arise.

Like any investment in a social program, take the time to put together a useful cross-functional plan that includes:

  • A well-defined scope
  • Clearly defined key roles between partners
  • Phases within the plan for all-important incremental wins
  • Risk-mitigation plans

Even with “small” SDOH data projects, there’s no race to the finish. That usually only leads to a breakdown in the process. Slowing down before chasing the next phase can lead to significant insights that change lives over time.

Let’s go back to Jeff in Arizona for a moment. Predictive analytics flagged Jeff as someone who could qualify for set-aside housing and other wrap-around services such as nutrition and health education, healthy food vouchers and referrals to health care providers and employment resources.

After a year, the payoff was enormous. After intervention, Jeff’s ER visits, hospital admittances and inpatient stays dropped to zero. And his average monthly cost of care plunged dramatically to $400, while helping him establish a better quality of living.

That’s no small drop. It’s what gathering SDOH data can do when there’s a big desire to improve a population’s well-being.

Learn more about using SDOH data to help improve clinical, financial and operational performance. Read the article “Social determinants: Completing the health data picture.”


About the author:

Andrew Cone HeadshotAndrew G. Cone
Sr. Vice President, State Government Solutions

Andrew Cone leads solution and business development/strategy for Optum State Government. His experience spans the health spectrum, including commercial, government (Medicare and Medicaid), payer, provider and pharmacy benefit services. A graduate of Hamline University in St. Paul, Minnesota, his career spans 30+ years and includes business and software development, service delivery and consumer engagement.


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