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.
“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.
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.
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.
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. 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.
Nurses play an all important role in healthcare’s shift from sick care to wellness-based models as the front-line professionals closest to patients. Always an intricate balance of art and science, nursing practice most continue to evolve to place patients where they should have been all along—in the center of care.
An independent survey commissioned by Wolters Kluwer of nearly 2,000 consumers, nurses, doctors, and healthcare executives in the U.S. provides insights into the top trends that will shape priorities over the next few years – for care teams, hospital leaders, health systems and consumers.
The below infographic details key findings related to challenges and opportunities impacting the nursing profession including perspectives on:
the impact of professional shortages
the growing importance of holistic care that addresses social determinants of health
generational differences between practicing nurses
More than ever, nurses need to demonstrate knowledge, confidence, competence, professionalism, empathy and kindness. And they need to be equipped with the right evidence-based tools and education resources to thrive in a changing healthcare landscape.
Addressing the social determinants of health (SDoH) in communities is a hot topic of conversation in healthcare. The industry has bought into the theory that 20 percent of an individual’s health is determined by clinical care and the rest by social, economic, genetic and behavioral factors. But perhaps more importantly health systems need to recognize that they can’t solve this issue on their own.
From my perspective at PCCI, I’ve seen an increase in value-based contracting models in recent years, and health systems and physicians are looking beyond the four walls of their institutions to build relationships with outpatient, behavioral health, post-acute care, and now non-medical providers. The number and types of collaboratives between health systems and non-traditional providers has been growing over the past several years with a recent report gathering information on more than 200 different partnerships between hospital and community-based organizations across the country.
But while health systems may be embracing community provider relationships, I believe that sustainable success in addressing social determinants of health requires a fundamental shift in the way health systems view their role in improving the health of their communities.
Over the past ten to fifteen years there has been an evolution in how health systems have approached improving health outcomes. Initially health systems focused on providing high-tech solutions for care delivery such as robotic surgery, and advanced imaging techniques. Then to meet the need for increased access and demand for outpatient services, health systems seeded service areas with ambulatory surgery centers, urgent care, retail clinics, and physician offices.
In each of these evolutions the strategies centered on a solution created by the health system alone. And one could argue that the main beneficiaries of these investments were often the health systems themselves – increased market share, improved reimbursements. But such a self-centered approach will not work when addressing social determinants where the root causes lie outside the four walls of the health system.
Effectively creating a system of community will require a collaborative mentality from health systems. While they may have power and influence to gather partners to the table, execution of successful interventions lies with social services and community-based organizations that are the experts in understanding and helping individuals address social needs. Even if not leading, health systems should still be active participants in this work. Indeed, there are areas where their contributions to the organization of partners is critical:
Carrot Health, a provider of healthcare solutions powered by social determinants of health (SDoH), announced it has been named a finalist in the Accenture HealthTech Innovation Challenge – Health North America. Carrot Health was one of 13 companies to compete in the Boston regional round of the competition, which supports innovative technologies and drives creative solutions to improve the way people access and manage healthcare.
“We are honored to have advanced to the finals in this important program. Innovation is the engine that drives crucial improvements in healthcare, such as the ability to leverage key SDoH data to close critical care gaps by addressing the non-clinical needs that impact as much as 80% of health outcomes,” said Kurt Waltenbaugh, CEO of Carrot Health. “The caliber of technology solutions presented by our fellow competitors in the Boston round of the HealthTech Innovation Challenge was outstanding, and we are honored to have been among them.”
Carrot Health, which moves on to the finals taking place in Houston in February 2020, was selected for its Carrot MarketView platform, which generates insights for growth, quality and health using social, economic, behavioral and environmental data. MarketView helps healthcare organizations by leveraging consumer and clinical data to deliver a 360-degree view of the patient.
Validated in the market, Carrot Health’s predictive models and insights have proven effective at:
Driving growth by identifying consumer needs
Improving health outcomes by influencing key performance metrics, such as emergency department utilization, admission/readmission, cost of care and mortality
Enhancing quality by closing care gaps and improving customer satisfaction
“MarketView encourages health organizations to address appropriate needs along the full healthcare hierarchy, identifying and eliminating bottlenecks before they can adversely impact quality, care outcomes and costs,” said Waltenbaugh.
Since its inception, the Accenture HealthTech Innovation Challenge has brought healthcare organizations and startups together to tackle the world’s biggest health issues. Over the life of the program, Accenture has received more than 2,200 applications, invited more than 90 startups to compete, benefitted from the time and guidance of nearly 1,000 executive judges, and awarded 10 trophies to the most innovative healthcare startups. The Health North America challenge brought together innovative startups across North America to compete in a challenge focused on solutions in the areas of operational efficiency, increased access and consumer experience.
The term “social determinants of health” is far more than a trendy new buzzword in health care. Serving the physical, mental and social needs of the community is not just the right thing to do but can mean substantial improvement in care and reduction in unnecessary healthcare costs.
Several studies have shown that addressing social needs, such as food or housing insecurity, can have a significant impact on a person’s healthcare outcomes and costs. Individuals experiencing housing insecurity or homelessness have higher rates of chronic diseases such as high blood pressure, heart disease, diabetes, asthma, chronic bronchitis, and HIV. This in turn leads to higher utilization of healthcare services such as emergency room visits, inpatient hospitalization and longer lengths of stay compared to those individuals with secure housing. Similar results are seen in those experiencing food insecurity.
Hospitals often state that part of their mission is to provide high quality care and improve the community’s health, or community benefit. A recent study of hospital mission statements in three states (Ohio, Florida and Texas) found that while quality was cited most often (65%), the second most frequently used term was community benefit (24%). If community benefit or community health is part of your health system’s mission statement, how much are you really doing to address the whole health of a community vs. just addressing their “sickness” needs?
At PCCI, our combination of data scientists and expert clinicians believe that health systems have an obligation to address social determinants of health to ultimately remove the disparities and inequality that we see in our community’s health. Yet this is tricky because success requires outreach skills, community relationships and data insights that extend beyond the traditional promise of health-related services. That said, there are three key elements that can assist health systems in making an investment in social determinants of health a reality. To move from theory to action, my suggestion is that health systems do the following:
Leverage the board’s community presence to align on areas of greatest need
As part of health system leadership, board members ensure alignment between mission and a defined SDoH strategy at all levels of the organization. As community representatives themselves, board members can also create the momentum and connections that health systems need to bring community and business partners together to create a governance structure for launching a connected community of care. Such governance structure will guide the strategy, legal and policy needs, and the investment and execution of a connected and aligned SDoH strategy.
Invest in long-term partnerships to ensure sustainability
Recognize that as health systems, you alone cannot solve for social determinants. To truly meet the social, behavioral and emotional needs of some of the most vulnerable individuals in your community, you need to identify community partners with expertise in these areas. With the assistance of board members, assemble a partnership collaborative, with a formal governance structure, to build community-based strategies around SDoH needs. Support the sustainability of this collaborative with technology and data science techniques to identify specific root causes of social need in target populations, share data, and measure impact of interventions. Identify an independent partner to evaluate the effectively of the SDoH initiatives and measure the cost, savings and impact across the community and for the health system.