By Baraka Floyd, MD, pediatrics physician at Stanford Medicine Children’s Health and Clinical Assistant Professor at Stanford School of Medicine and Lindsay Stevens, MD, pediatrics physician at Stanford Medicine Children’s Health and Clinical Professor at Stanford School of Medicine
The emerging focus on social factors that influence health outcomes has necessarily transformed the approach clinicians take in patient care. These factors, otherwise known as “social determinants of health (SDOH),” include food insecurity, housing and utility instability, transportation access, and personal safety, among others. These have a tremendous impact on long-term health outcomes and quality of life.
When problems arise in these areas, patients and families struggle to focus on medical needs. As a clinician, identifying and keeping track of these social determinants of health help create the opportunity for patient-focused solutions. This could be the difference between a food insecure family gaining access to resources and that same family not being aided appropriately.
Food insecurity as an example of a social determinant of health
More common among families with children, food insecurity impacts more than 34 million people, including nine million children in the United States. It is a lack of consistent access to food for every person in a household to live a healthy life. Influenced by several factors that includes income, employment, race, ethnicity, and disability status, food insecurity has been exacerbated by the COVID-19 pandemic.
As the pandemic left many households with limited food access and financial opportunities, numerous families were forced to rely on food assistance programs for the first time. As even more families faced a lack of access to sufficient food and nutrition, health care providers had to ensure that they addressed food insecurity as a key determinant that impacts their patients’ long-term health.
The cost of healthcare disparities has been long and deeply felt by patients and their families, but it wasn’t until the high rates of COVID-19-related hospitalizations and deaths among persons of color made headline news that the broader societal impacts of health disparities became more widely known. In response, health systems are prioritizing health equity and leveraging new tools and data to support their work.
At a physiological level, the presence of underlying chronic disease increases the risk presented by COVID-19. The incidence of chronic disease(s) is increasing among all Americans, but the prevalence is much higher among the poor, which includes a higher percentage of individuals of color compared to the overall White population.[1] Health inequities among communities of color are further exacerbated by structural and institutional racism, which experts say “harms health” because of negative factors in their physical, social, and economic environments and a propensity to develop maladaptive coping behaviors (e.g., smoking, alcohol, etc.)[2].
A Community-Level Issue
Increasing rates of chronic disease create a self-reinforcing cycle that threatens the well-being of entire communities (and the health systems that serve them). Individuals suffering from chronic disease have higher rates of absenteeism,[3] which limits their wealth building potential, the productivity of their employers and the tax base of their communities. This, in turn, increases poverty and the impact of the social determinants of health (SDOH) that contribute to higher rates of chronic disease. The combination of chronic disease (as an inflammatory condition) and the psychological stress of racism have been shown to cause physiological changes that raise the risk of contracting additional chronic diseases.[4]
Hospital performance is also tied to economic well-being. Research documents a correlation between the quantity and quality of local economic resources and the clinical performance of hospitals, which under value-based payment models, can also impact financial performance.[5] With chronic disease responsible for nearly 90% of national health expenditures,[6] it’s continued rise threatens our national economy and the ability to fund needed healthcare for the poor and aging. In other words, this is not just a social issue; it is an economic imperative. A 2021 Institute for Healthcare Improvement (IHI) study found that 58% of healthcare executives ranked health equity as one of their organization’s top three priorities, up from 25% in 2019.
Across the United States, persistent and growing gaps in care are driving health disparities and presenting barriers to improving overall health and health outcomes. Many health disparities stem from inherent inequalities in social determinants of health (SDOH), such as where a person lives or works, their education level, and their access to healthcare.
Health equity — defined by the Robert Wood Johnson Foundation as when everyone has a fair and just opportunity to be as healthy as possible — is not a new concern. For decades, health equity has been in the spotlight within the public health realm. But the COVID-19 pandemic brought the topic of health equity to the forefront like never before. Something once discussed only among policy experts, advocates, and health communicators is now mainstream news and discussed around the dinner tables of Americans across the nation every single day.
As COVID-19 quickly spread, it became increasingly apparent that minority patients were disproportionately affected compared to other populations. A recent study found that Black people were 3.57 times more likely to die from COVID-19 than white people. The reasons are varied: Multigenerational families and insufficient access to care contributed to higher infection and mortality rates for minority populations. This disparity serves as a reminder that systemic inequalities persist across many facets of American society.
Social determinants of health can be far reaching
SDOH often present barriers to care. Research has shown that when assessing a person’s health, their ZIP code is often more predictive than their genetic code. But despite their prevalence, SDOH should never dictate health outcomes or the quality of care a patient receives.
Typical attempts at defining, quantifying, and measuring social determinants of health (SDoH) are limited to geographic or population averages, which often mask individuals’ discrete and unique experiences. They can, therefore, lead organizations to implement costly and inefficient programs instead of addressing individuals’ actual barriers that represent the greatest potential for improving health outcomes and return on investment.
Recognizing this, the Colorado Hospital Association (CHA) sought to gain a better understanding of the unique fingerprint of risk within its members’ patient populations—knowledge that would lead to more effective strategies for its members to address emergency department (ED) super-utilization and readmission rates with interventions that would produce the greatest return on investment.
The group partnered with Carrot Health to perform a statewide analysis on the relationship between ED utilization and readmissions and SDoH. Coupling claims data from CHA’s On Demand Hospital Information Network (ODHIN) and consumer behavior data from the Carrot MarketView platform enabled production of an industry-first analysis of healthcare utilization across Colorado.
SDoH and Readmission
The analysis provided deeper insights into the patterns and relationships observed through patient data, social risks, and ED utilization and readmissions. The latter – readmission – is a core utilization metric that has been identified by Colorado’s Medicaid payer as a key metric impacting hospital reimbursement under Colorado’s value-based Hospital Transformation Program (HTP). As a result, improvements in readmission and optimization of quality programs around it are paramount to CHA’s member hospitals.
Readmission is also an area where SDoH can have a significant impact, particularly within the Medicaid population where social determinants are often exacerbated. For this reason, the CHA determined that identification tools would play an important role in helping to quantify risk and identify opportunities for strategic program design, community outreach, and interventions by allowing for the visualization and highlighting of the relationship between readmissions and SDoH.
This would, in turn, allow CHA to determine the appropriate guidance for member hospitals seeking improvement in their quality efforts. To that end, CHA and Carrot Health constructed an interactive dashboard to help hospitals understand their specific patient population by identifying those who had been readmitted within 30 days and which SDoH were contributing to overall risk for readmitted patients.
The dashboard allows CHA to identify areas of increased social risk for by comparing patients who were readmitted against those who were not. It also allows member hospitals and health systems to examine patient populations by ZIP Code, payer, race/ethnicity and SDoH risk groups and draw insights within each population.
The healthcare business of LexisNexis Risk Solutions announced a collaboration with Carrot Health, a provider of solutions powered by consumer and healthcare data. The collaboration enables Carrot Health to incorporate social determinants of health (SDoH) data from LexisNexis Risk Solutions into its SDoH data and analytics software platform to guide payer and provider decisions around member engagement and health management.
Through this collaboration, Carrot Health will integrate clinically-validated SDoH attributes from LexisNexis Risk Solutions into its existing Social Risk Grouper (SRG) taxonomy and other predictive models that leverage vast consumer and healthcare data. These insights will inform consumer-centric strategies to improve health outcomes, reduce costs and prevent readmissions.
Kurt Waltenbaugh
“Consumer attributes are among the most powerful factors influencing health outcomes, creating barriers and inequities that prevent populations from leading their healthiest lives. Carrot Health’s SRG harnesses this information to measure and monitor social determinants of health at the individual level, providing comprehensive insights our customers need to design strategies for identifying and closing gaps in care while providing a more personalized member experience,” said Kurt Waltenbaugh, CEO, Carrot Health. “We chose LexisNexis Risk Solutions after extensive evaluation and testing because their consumer data proved to be the most accurate and comprehensive in the market. We are excited about this addition to our platform as we continue to help payers improve member health.”
Carrot Health’s platform harnesses clinical, social, economic, behavioral, and environmental data to deliver insights for growth, health, and quality, providing health plans with a 360-degree view of their members. Carrot Health is delivering the healthcare industry’s first solution for consumer insights at scale, along with individual-level SDOH scoring and monitoring for every adult in the United States.
This scoring model helps predict the likelihood of an individual having an adverse health outcome due to their SDoH profile. The data from LexisNexis Risk solutions will augment Carrot Health predictive models, that already includes consumer data, ICD-10 Z-codes, publicly available health indicators, claims, survey responses, and other proprietary data ? providing unmatched accuracy to a scoring model.
More than a year after scientists identified the first cases of COVID-19, infection rates continue to rise in regions across the United States.
The virus has been particularly devastating for those who can afford it least: the elderly, underserved communities, low-income families, and people of all ages with chronic conditions.
COVID-19 infection, hospitalization, and death rates for these groups are dramatically higher than for other populations.
According to the CDC, eight out of ten reported COVID-19 deaths in the US are among individuals 65 or older. And data from the COVID Tracking Project reveals that Black or African American individuals are up to 1.5 times more likely to die from COVID-19 than white patients.
Patients with multiple chronic diseases are also at elevated risk. The CDC cites chronic kidney disease, COPD, obesity, and heart conditions as known contributors to poor outcomes from COVID-19, while Medicare statistics show extremely high rates of hypertension and hyperlipidemia, diabetes, and chronic kidney disease among hospitalized beneficiaries.
All these groups have another major risk factor in common. They are the populations that most often struggle to cope with the social determinants of health (SDOH), such as food security, social isolation, and access to healthcare, living wage employment, and transportation.
In the current economic environment, many of these individuals are even facing the hard choice of prioritizing food and shelter over the expenses of necessary healthcare and medications, despite the knowledge that avoiding care may increase their vulnerability to their preexisting conditions – and subsequently raise their chances of experiencing a worse outcome if they contract COVID-19.
Even with the prospect of mass vaccination on the horizon, it’s more important than ever for healthcare providers and health plans to understand and address the social determinants of health, starting with ensuring pharmacy access and medication adherence.
The role of medication adherence in population health management
Population health management focuses on staying one step ahead of the clinical and non-clinical factors that may lead to poor outcomes in targeted patient groups. For the six in ten Americans with at least one chronic disease, medication adherence is a critical component of maintaining good health.
Suboptimal medication adherence has significant impacts on chronic disease management and overall wellbeing. Incorrect use of medications contributes to tens of thousands of preventable deaths and half a trillion dollars in healthcare waste every year.
The reasons behind medication adherence issues are varied and challenging. Some patients experience undesirable side effects and change their doses without consulting their physicians, while others struggle to understand the importance of their prescriptions or fit their medications into their daily routines.
For patients with socioeconomic difficulties, the problem gets even more complex. Out-of-pocket drug costs are skyrocketing, leading large percentages of patients to abandon their medications unwillingly.
By Julie A. Pursley, MSHI, RHIA, CHDA, FAHIMA, director of health information thought leadership, AHIMA.
Julie A. Pursley
Reading news articles about vulnerable communities disproportionately affected by COVID-19 has been heartbreaking. My organization, the American Health Information Management Association (AHIMA), believes that social determinants of health (SDOH)—the socio-economic behavioral elements that affect health—play in role in explaining why poorer communities have experienced more negative impacts during the pandemic than other areas. We also believe it’s vital for SDOH information to be recorded in medical records.
It’s not difficult to imagine why low-income Americans may face increased exposure to the novel coronavirus. Perhaps most critically, people experiencing poverty are more likely to not have health insurance or be underinsured.
In addition, while many office workers have worked from home during the pandemic, people who earn lower incomes often work in public-facing jobs like restaurants and grocery stores and have no choice other than to take public transit to get to work. And the millions of Americans who have lost jobs may be dealing with food insecurity and a lack of money available to secure food and other goods at home.
Communities of color often comprise low income workers who encounter many of the situations mentioned above (and more). At AHIMA we support collecting race and ethnicity data for optimal public health reporting because recording SDOH information in a patient’s medical record can lead to better healthcare outcomes. SDOH information in a patient record offers providers a more complete story and can influence how they approach treatment, education, and care management.
“We’ve had physicians across our practices reach out to patients living alone during this time of social isolation, those who were identified as potentially being isolated and without support,” William Torkildsen, MD, chairman at South-Texas-based independent physician association Valley Organized Physicians (VOP), recently told the Journal of AHIMA. “We recorded those results and have been able to take action on the patient’s behalf, connecting them to necessary resources.”
It is encouraging to see many healthcare systems and payors focusing on the impact of social determinants of health (SDoH) and looking for ways to partner with community-based organizations to address and improve these issues locally. Although this is a necessary step, I believe that providing access or referrals to community organizations is not the full answer.
While healthcare systems can provide referrals and connect patients to resources such as food banks or employment resources, it may not be enough to create individual engagement and empowerment to use those resources. We more fully need to appreciate the role played by the environment in which we grow up and the choices available to us in shaping how we respond toSDoH factors as individuals.
As part of an innovation center where we align data science withSDoH to help systematically disadvantaged individuals, I’ve been witness to projects and research that point to the theory of individual resiliency as part of the equation. The American Psychological Association defines individual-level resilience as the process of adapting well in the face of adversity, trauma, tragedy or threats.[1]
A review of the research on resilience by the WHO found that an individual’s ability to successfully cope in the face of significant adversity develops and changes over time, and that interventions to strengthen resilience are more effective when supported by environments that promote and protect population health and well-being. Further, supportive environments are essential for people to increase control over the determinants of their health.[2]
Also, in addition to traditional resilience methods, the emergence of methods to assess an individual’s capacity for self-care are adding significant insights into personal determinants of health. In particular, the needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care.
Clinical teams need to acknowledge, respect and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Further, clinical teams need to ensure that social and community workers and public health policy advocates are part of the proposed solution. Researchers at the Mayo Knowledge and Evaluation Research (KER) Unit and the Minimally Disruptive Medicine (MDM) program led by Dr. Kasey Boehmer are developing qualitative methods and measures of capacity and individual’s ability for self-care.
Take post-traumatic stress disorder (PTSD), as an example. It has been estimated that around 50-60 percent of people in the US will experience severe trauma at some time in their lives. Around one in 10 goes on to develop PTSD, which is permanent in a third of cases.
But some people who have lived through major traumatic events display an astonishing capacity to recover.[3] A complex set of factors can be attributed increasing an individual’s resiliency to trauma including their personality, their individual biology, childhood experiences and parental responses, their economic and social environment as shaped by public policy, and support from family and friends.
By Baraka Floyd, MD, pediatrics physician at Stanford Medicine Children’s Health and Clinical Assistant Professor at Stanford School of Medicine and Lindsay Stevens, MD, pediatrics physician at Stanford Medicine Children’s Health and Clinical Professor at Stanford School of Medicine
By Kurt Waltenbaugh, CEO, 
