Unlock the Clinical Value of SDoH Data Through Analytics

The transition to value-based care (VBC) and accountable care organizations (ACO) over the past decade has been slow. But the progress is undeniable and is building momentum.

More than half of health care organizations today participate in alternative payment contracts, and 41% of health care payments in the United States in 2020 were tied to value- and quality-based payment models, up from 38.2% in 2019.

These models are designed to reduce costs while fostering appropriate patient care and positive outcomes. To achieve these goals, health care organizations must understand and address social determinants of health (SDoH), the social and economic conditions that impact the health of individuals, communities, and populations. Research shows that SdoH account for up to 80% of health outcomes, with clinical care accounting for the rest.

While there is broad awareness of the role SDoH play in overall well-being and in achieving value from health care and services, we face a contradiction, as noted in a recent white paper published by the Leonard Davis Institute of Health Economics at the University of Pennsylvania:

“While patients in ACOs tend to have a higher clinical risk, providers in communities serving populations with social risk factors are less likely to participate in ACOs.This may be, in part, because care for populations with high social risk is typically concentrated within a subset of providers, such as Federally Qualified Health Centers (FQHCs). More troublingly, some ACO models may emphasize reducing wasteful utilization, but for many populations the primary problem is under-utilization and underspending.”

As the study points out, high-value care in some cases may mean more services and more spending.

SDoH data can hold the key to understanding and prescriptively targeting care and services. Awareness of SDoH value does nothing to improve health outcomes if data can’t be gathered and analyzed for insights. Electronic health record (EHR) systems weren’t originally designed to capture SDoH data, so even if staff wanted to collect these data, there was no place to easily record and retrieve it. If data was captured, it often went into free text note fields often buried 4 screens deep, providing little clinical or analytical value.

As the importance of SDoH has become more apparent, EHRs’ data schema have, in many cases, evolved to enable data capture related to a patient’s living situation, employment, access to healthy foods, sense of physical safety, access to transportation, and other SDoH. Capturing this information in the EHR can knit together risks and complexities that otherwise would have gone undetected.

With this greater awareness of SDoH and EHR evolution, there has been marked progress in collecting and recording data to foster whole-person care. However, we are just learning how to marry this medical model—whether it involves primary care or behavioral health—to social services.

Until we do, we may be inadvertently suboptimizing care in our quest for value. As the University of Pennsylvania white paper found, some ACO models may emphasize reducing wasteful utilization, but for many populations the primary problem is underutilization and underspending.

Using SDoH to Fuel Innovative Programs

Emergency department (ED) utilization by homeless patients is 3x the national average and has increased 80% over the past decade. While not directly causational, numerous studies show housing is key to reducing ED utilization. A monthly rent of $1000 is the equivalent of 45 minutes in an ED.

Some communities’ health care organizations are taking a more active position in housing vulnerable members of the community to address this challenge. For example, hospital systems in Portland, Oregon, collaborated to fund $21.5 million in housing for high-risk individuals, knowing stable housing reduces costs and improves quality of life for those individuals in the long term. Recent data from the Portland “Housing is Health” initiative shows annual savings in ED and criminal justice-related expenses of $20,000-$30,000 per client.

Leveraging SDoH Data to Drive Value

Taking full advantage of SDoH in support of VBC requires 3 things.

First, EHR and app developers must continue to enhance capabilities to capture socioeconomic data and develop analytics at the patient and population level to support socially derived care. There’s no value in a provider’s frontline staff asking questions about safety or nutrition if nothing is done with the information gathered from the patient. Providers need whole person data for early interventions.

A second requirement is for providers to build a network for community referrals and care coordination. Our health care system is good at creating links from Point A to Point B and Point C, but life isn’t linear, especially for patients with complex conditions. What is needed are safety webs across the health care ecosystem. Innovation around SDoH can be the framework upon which we build these webs.

Third, providers must focus on proactive care and outreach, which are the essence of VBC. In some cases, this may mean more care and services, not less. This reflects the importance of SDoH and analytics to extract meaningful information about socioenvironmental factors that impact health. This knowledge, obtained through robust data and information across the community of care providers, will produce better patient and population health outcomes while reducing care utilization costs.

No Time to Waste

If organizations such as community health centers and social service agencies could easily capture and report more SDoH data, such as referrals to Meals on Wheels, and tie that data to medical and behavioral health outcomes at the patient and population level, it would reinforce the value of more services and spending for targeted populations.

Today, building a broad data set for SDoH is a catch-22 because we don't know what data is the most important to collect. Care providers and agencies are collecting a lot of data without fully understanding its overall potential utility. However, we are beginning to establish a cumulative baseline of evidence to help us determine what data, interventions, and social determinants matter most in terms of outcomes across disparate populations.

SDoH data can tell us what is happening beneath the surface. Layering in social factors, such as employment status, nutritional issues, or safety offers a more nuanced picture of the whole patient rather than one based strictly on a specific health condition. This then enables providers to maximize the value of care and services more effectively and appropriately.