Intelligently and Virtually Managing Social Determinants of Health

Published May 5, 2020

As the American healthcare landscape becomes increasingly complex and the cost of care continues to skyrocket, the system is working together to achieve better healthcare outcomes and drive down costs. For over 20 years, CareCentrix has been focused on this trend by taking an uncommon approach:  creating more healthy days at home. In many cases, care too often defaults to an acute setting due to an inability to control not only clinical but also non-clinical needs, better known as Social Determinants of Health (SDoH).

Recently, Melissa Carr, General Manager of Home Services, and Jon Terenzetti, Vice President of Data and Technology, joined Ashish Shah, CEO and Co-founder of Dina, and Krupa Srinivas, Co-founder of Owned Outcomes, on a webinar to discuss the role of SDoH. In particular, the group discussed how the larger healthcare industry can focus its efforts on often-ignored factors, including the environment, family, and socio-economic status, to ensure a more coordinated approach to care. Below are our main takeaways from this conversation, and we invite you to watch the on-demand webinar recording here.

Thinking beyond Clinical Care

What is happening outside of the doctor’s office impacts how we deliver and manage care. According to HIMSS, roughly 80% of a patient’s health outcomes are determined by non-clinical factors in their home and family environment.1 This is why patient risk assessments that focus only on clinical factors, claims, and comorbidities often come up short.

At CareCentrix, we use personal assessments and data sets of both clinical and non-clinical factors when planning for care post-discharge from a hospital. And since patients are often leaving with multiple new prescriptions and referrals, it’s critical to fully understand a patient’s barriers – whether they are financial or transportation issues – to provide the most comprehensive care.

Local Insights Matter

Healthcare is localized and personal, which is why implementing a data-rich approach that goes beyond zip code is crucial to understand a patient’s needs. For example, at CareCentrix, we break down insights at the individual block level, ensuring our recommendations are tailored for the exact patient – not an average of their entire town. With over 80 data elements available in over 200,000 block groups, we are able to base our insights on a precise layering of demographic and socioeconomic data onto clinical history.

In a recent internal study of over 50,000 patients, we identified that the most critical factor for determining whether a patient would be readmitted was access to quality food, either through grocery shopping or via delivery. Interestingly, living near a meal delivery provider (such as Meals on Wheels) decreased risk of readmission more than any other non-clinical factor. These insights allow us to focus resources on individual patients and their situations where we know our interventions will drive improved outcomes and increased patient comfort.

Realizing the Benefit

It’s not enough to understand that a patient is going to need food, transportation, or a smoking cessation program. It’s imperative to understand a patient’s needs, which can extend beyond their healthcare journey, while also taking SDOH into account.

At CareCentrix, we combine information from a rich set of public and proprietary data sources, including evidence-based clinical assessments, so that we can better understand and meet all of our patients’ needs. This is becoming more important as the healthcare industry understands how to leverage technology to address SDOH, and ultimately fill a critical care gap that exists between hospitals, providers, and patients.

We know that patients are used to being told what to do, but they are rarely given the help and support they need. Providing ample support that addresses the various factors in a patient’s life can be the key to build a comprehensive program that addresses the entire care continuum.

1 https://www.himss.org/news/social-determinants-of-health-data-to-improve-patient-care