By Michael Ipekdjian, CarePort Health
There is a hot buzzword around town: Social Determinants of Health (SDOH). Currently defined by The World Health Organization (WHO) as, “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life,” SDOH plays an integral role in holistic patient care that extends beyond the hospital or doctor’s office. Socioeconomic status, political systems and social norms all contribute to an environment in which individuals thrive or experience challenges.
Historically, health systems have focused on ensuring patients are treated appropriately during their time at a hospital or clinic, with little attention paid to the environments patients face at home. With so much emphasis on caring for the sick, the importance of a patient’s socioeconomic status, including their living conditions and lifestyle – all things that have the potential to majorly impact their health – are often overlooked. For patients with life-threatening conditions or chronic illnesses, helping them make certain changes to their lifestyle has the potential to significantly improve and sustain their health, and ultimately improving the quality of care.
Unfortunately, not all hospitals have enough case managers or the right tracking technology to follow their patients’ journey across the full care continuum. As an industry, how can we do better? What tools are available today that allow providers and care managers to better track their patients after they leave the hospital?
While it’s not as simple as flipping a switch, there are technologies available today that can better track a patient’s well-being across the continuum of SDOH. These same tools can provide real-time actionable insights and speed up manual processes for providers and care managers to empower more holistic, thoughtful and impactful care.
Understanding The Impact Of Social Determinants Of Health
Having spent much of my career as a case manager and nurse, I’ve seen many instances of poor SDOH tracking. For example, we had a diabetic patient who consistently had very high A1C levels, failing to control his blood sugar and not taking his medication appropriately. As a result, we conducted a home visit to better understand why this kept happening despite his physician’s best efforts. We learned this patient had no family support system and did not understand that drinking soda could contribute to high blood sugar. By identifying this patient’s real-life barriers to achieving better health, we were able to provide the kind of support and education the patient needed to take control of his disease.
Examining social determinants of health does not need to be overly complex. The hospital I previously worked for built a navigation program aimed at very simple activities, such as going through patients’ cabinets to see their food choices. The food a person eats has a huge impact on their health and a quick look in the pantry can be very telling. It also was very common to discover that patients with breathing problems didn’t have air conditioners, or those with heart problems often didn’t understand the need to monitor their daily sodium intake. These are simple things to figure out if you know where to look — and the impact can be huge.
Technology’s Stake In SDOH
Hospitals and health systems working to address the social determinants of health have found technology is imperative for collecting real-time data and exchanging valuable insights across the care continuum. While there isn’t a standard approach or solution, many health organizations are taking their own “homegrown approach” by using their current EHR to collect and use social determinants data for various projects. A recent article quotes Dr. Robert Fields, SVP and CMO for population health at Mount Sinai Health System, stating, “the technology solutions that are most beneficial for social determinants of health work include predictive analytics, network registries of community-based organizations and referral platforms as part of care management solutions.”
At CarePort, the topic of social determinants of health is certainly top-of-mind. While our technology was not developed specifically to manage SDOH, our solutions all provide a view into how the patient is doing throughout transitions of care. Should a patient end up back in the ED – like the diabetic patient who needed intervention – there is a documented history of where the patient has been and context about their diagnoses and progress for more focused follow-up.
By understanding a patient’s full health history (e.g. where the patient has been treated, how they have been managing their health, their treatment at those locations and their discharge plans from post-acute providers) we can better understand patterns. Looking at this data, and putting all the pieces together, enables our customers to understand what’s occurring in between the transitions of care and identify gaps that may be causing the patient to return to the ER.
As the industry continues to shift toward value-based care, the need for visibility into all of the factors that contribute to a patient’s wellbeing is increasing. By looking at the social determinants providers and payers can improve patient care and overall population health.
About The Author
Michael Ipekdjian, Director of Customer Success at CarePort, is a former bedside nurse and inpatient acute case manager and also has held multiple senior care management roles. He holds an MBA in Healthcare Management from Western Governors University. Prior to joining CarePort, Michael was the Corporate Chief Operating Officer of Better Health Your Way. He also served as Director of Transitional Care Management at Holyoke Medical Center.