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Healthy People 2030 cites addressing social determinants of health as one of its five overarching objectives: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” This gives health care policy makers, care teams and community stakeholders the chance to consider how partnerships, technology and reimbursement opportunities might help their organizations promote social services to sustain ongoing support and change. But will their activities carry the weight needed to reduce health disparities and prove long-term commitment to change?
How can you impact a population’s needs?
1. Prove leaders’ commitment by setting a long-term vision centered on the structural root causes of poverty and health inequity. Identify local needs and resources.
- Avoid implementing stand-alone projects or services that might work for others, but not for your population. Short-term fixes often translate to misuse of resources and alienate the community.
2. Use multiple modalities to identify social needs and resources.
- Geospace data can help shed light on a community’s engagement and behavioral patterns—in particular, for providers seeking to develop a network of community-based organizations (CBO) and demonstrate value through collaboration.
- Screening questions help organizations understand people’s (and patients’) perceptions of need. Implementing a standard mechanism for capturing data in an EHR and other clinical tools allows proactive engagement.
- Engagement through a referral management system helps providers and CBOs:
- Understand their population’s ability to acquire, satisfy and prioritize health needs.
- Understand available community resources and social gaps.
3. Enable structured delivery of services and workflows that promote proactive member connection through one-on-one support and self-management.
4. Build community partnerships to create solutions that reflect the community’s voice.
- How do you assess appropriate partnerships? Tools and referral management systems often have great insights into CBOs’ offered services, adoption to workflow and technologies and service capacity.
5. Integrate Z codes into standard screening results and intervention workflows to establish reporting, structured interventions and (hopefully) compensation model alignment.
6. Establish value-based payment or contractual arrangements that encompass support of strong partnerships and CBO engagement—ultimately leading to a compensated network of providers, vendors and organizations focused on the same mission.
7. Demonstrate the impact and value of interventions and program designs.
- This is challenging! Evaluate and align your goals and vision with core competencies to identify desired results and process measures that will enable your team to demonstrate improvement over time.
8. Gather data, evidence and best practices and structured workflows to help policymakers understand the ideal approach to sustaining resources and fundamental requirements such as compensation—leading to operational scalability that goes beyond traditional pilots.
To accelerate success, organizations must design, implement and monitor solutions that prioritize individuals’ empowerment while building CBOs’ capacity to respond to unmet social needs. Use a whole-person model that reflects community and patient needs, leverages meaningful partnerships and structured interventions and tracks the use of resources, data and technology integration.
1. What results or evidence resulting from data or technology addressing SDOH has your organization observed?
2. What lessons can you share after implementing SDOH strategies?
3. What challenges are you experiencing with integrating or adopting SDOH tools and interventions?
Vanessa Guzman,CEO,SmartRise Health
Vanessa Guzman is an expert in population health strategies, including patient and physician engagement strategies, clinical reporting, health IT and quality management models, and CEO at SmartRise Health. With almost 15 years of industry experience, she works closely with health systems, Accountable Care Organizations (ACOs), technology, and SDOH partners to collaborate in implementing data-driven tools, clinical infrastructures, and community partnerships to promote wellness and improve patient health outcomes.
Vanessa served as the Associate Vice President at the Montefiore Health System, a top-performing ACO in the country, overseeing physician partnerships, population health and quality improvement, and health information technology.