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How social determinants of health can enable value-based care

May 07, 2021
Health IT
Rahul Sharma
By Rahul Sharma

It has been clear for years that social determinants of health (SDOH) – factors such as education, economic and housing stability, community support, and access to transportation – have a disproportionate impact on health outcomes. Research shows that SDOH accounts for up to 80% of health outcomes, while medical care – which costs the U.S. nearly $4 trillion annually – accounts for the balance.

What has been far less clear is how providers and payers can fully harness SDOH data to proactively manage the health of patients and members. Technological and cultural barriers have made it difficult for disparate parties such as hospitals, state agencies, mental health services, payers, law enforcement, community support organizations, and emergency services to share SDOH data in a way that would enable better coordination of care on an individual and community basis.

It is no coincidence that the intensifying interest in SDOH over the past five years has paralleled the growing interest among providers and payers in value-based care (VBC) models. The ultimate aim of VBC is to improve patient outcomes while lowering healthcare costs. Understanding and accounting for the impact of SDOH are keys.

“Addressing social determinants of health requires an all-hands-on-deck approach that is not limited to stakeholders within the health care system,” said AMA Board Member David H. Aizuss, MD. “By addressing social determinants of health in their benefit designs and coverage, health plans can be part of the effort to improve patient health outcomes.”

Making that goal a reality means adopting a holistic approach to care for patients and plan members that encompasses health and lifestyle, education, social services coordination and referrals, and population health initiatives. SDOH data is critical to providing the 360-degree view of individuals and specific populations that allows VBC to succeed.

What healthcare needs to make VBC work is a way to combine the medical and social mechanisms and data to form a comprehensive view of care management. However, this would require SDOH data to be shared between healthcare stakeholders, and that has proven to be a challenge.

The underlying technology must incorporate a consent management capability to ensure patient-permissioned data sharing with an immutable audit trail of disclosures. It also must support multi-channel communication approaches for obtaining and managing consent, such as mobile applications, secure text, audio, and video. If consent is being obtained through a caregiver, then Electronic Visit Verification (EVV) capture is another key data point that should be recorded.

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