Completing the health data picture

Including social determinants to drive better outcomes

There’s a scene in the classic movie “The Wizard of Oz” that shows Dorothy’s house tossed around in the air by the force of a twister. From the start of the movie until that point, the film is shot in dull, black-and-white tones — a monotone wash of gray.

Then the house crash-lands in Oz. When she opens the door of her home for the first time, Dorothy is greeted by a spectacular vista of color and layers of marvelous detail. She’s opened the door to an entirely new world.

While there’s certainly no fantasy involved in data analytics, there’s a similarity to be found in trying to improve population health with only traditional health care data — it’s often a wash of gray. But add the data gleaned from analyzing non-clinical factors and it can produce insights that are rich, multidimensional and impactful.

Analyzing data related to social and behavioral health factors, known as social determinants of health (SDOH), can help your organization avoid making decisions based solely on partial data. Ranging from ZIP code, education level and access to food, to employment, housing stability and reliable transportation, SDOH data adds color and clarity.

A critical role

There’s increasing evidence about the ways socioeconomic factors and lifestyle choices affect a person’s well-being. In fact, they may have a greater impact on overall health than health care services themselves.

Health plans, providers and employers have traditionally relied on data from within their organizations, rather than SDOH data outside their walls. Depending only on clinical data often delivers an incomplete picture of the patient or employee.

It’s not uncommon for organizations to have population data disconnects and gaps. Gaps and other data limitations can lead to shortcomings in information about health status, well-being and social concerns.

Access is another challenge that requires a better understanding of SDOH. Many uninsured or underinsured people can’t afford health plan costs, or they live in areas that don’t offer qualified health care providers. These are people who may present to emergency departments (EDs) for care that could have been prevented or may not even be needed. Along with concerns about how to address the safety and well-being of these individuals, this ED-as-a-first-resort approach drives up the cost of care and places health care organizations and patients at major financial risk.

Improve care, costs and accuracy

Studies show that SDOH and behavioral propensities account for 60% to 80% of health outcomes and utilization. Using analytic models allows providers and health plans to prioritize and drill down to “need” and “want” levels. The result? A more efficient use of care management and quality resources.

Understanding the impact of social determinants is one of the major ways health care is changing for the better. Incorporating SDOH data into health plans and systems can positively affect a number of areas, including:

• Strategic planning

• Community outreach

• Quality measures

• Value-based contracting

These data sets may also pinpoint the individuals or patients who are most likely to respond.

Serve communities and lower expenditures

As careful attention is paid to food, transportation, housing and other socioeconomic needs, costs can be brought into line. This requires often-siloed health care and social services systems to come together to serve their communities fully, contain costs and improve health outcomes.

Picture this real-life scenario for your organization — one state’s Medicaid program created housing support for more than 10,000 of its highest-cost and highest-need beneficiaries. After just one year, there was a 40% reduction in the program’s patient hospital stays and a 26% cut in ED visits.

Positive health outcomes

When SDOH data isn’t incorporated into your analytics, your choices and investment strategies may be influenced by an incomplete understanding of your patients, employees or constituents. Knowing how social determinants and barriers to health affect these groups can save you a lot of time, effort and resources. There’s no wizardry to it. But you’ll find that SDOH data open the door to a richer, clearer picture of the people and communities you serve.

Today, capturing data outside the health system walls is more critical than ever.