Skip to main content

How partnership, data and analytics can help supercharge SDOH outcomes (part 2 of 2)

In the first part of this blog, we discussed the “Discover” phase of working with community-based organizations to address social determinants of health. Next we’ll discuss the other steps in the Discover-Plan-Act cycle.

In planning SDOH strategies, hospitals and health systems, guided by their Community Health Needs Assessments, are often best able to identify and convene key partners to address SDOH. The CHNA process brings neighboring healthcare providers and community-based organizations together to:

  • learn from one another;
  • gain commitment;
  • share expertise;
  • understand public policy efforts; and
  • leverage technical and hands-on assistance.

But, are these efforts sufficient? The recent HealthLeaders Social Determinants NOW Summit highlighted the conversations needed to identify, solve and scale collaborative SDOH programs with CBOs. The summit showed the importance of identifying, expanding and improving existing CBO wish list programs. In other words: leverage, scale, improve and sustain. 

However, there are real and perceived barriers to overcome. A January 2022 article from the Journal of the American Medical Association notes, “Such efforts will require overcoming challenges with addressing upstream [SDOH], including … the lack of clarity about who should pay for the interventions, and disincentives to cross-sector collaboration.” 

In many cases, these disincentives simply include things that haven't been done before. Hospitals and health systems can lead here, paired with shared governance so that each partner is empowered to do what it does best. 

The HealthLeaders summit also noted that many providers and CBOs are already locked into specific funding and contract cycles. And while this is a very real constraint, not every SDOH program needs a new legal/contracting component. The parties should look for opportunities to formally commit to initiatives and not assume obstacles that may not exist.

How do you feel about your data and healthcare analytics?

Data-sourced analyses — created by using primary data from community surveys and from public and privately curated sources — can help hospitals, health systems and CBOs find the rationale they need to support strategic and programmatic initiatives. SDOH data are often the “missing piece,” providing information not found in electronic health record and claims data, covering: 

  • finance;
  • food;
  • housing;
  • transportation;
  • health literacy; and 
  • digital.

DataGen is able to license these SDOH data and analytics from its partner, Socially Determined. DataGen can free up your resources by integrating Socially Determined’s social metrics with your data, analyzing and interpreting their combined intelligence. In doing this, we deliver deeper, more customized insights to help you improve outcomes at the individual and community health levels. 

Taking action: Your next steps

There is a clear need for better data sharing between providers and CBOs to address SDOH in a more integrated way and to apply analytics for design, implementation, measurement and adjustment. Even with an analytics-first approach, providers and CBOs must take care that they match programs to populations. To avoid big changes in the early stages of this work, SDOH partners must be willing and able to listen to the needs of individuals and, if necessary, pivot from what the data-only story is telling.

As much as hospitals may want to make up for lost time, sustainable SDOH outcomes cannot be rushed. Initiatives are often not about quick wins but learnings, progress and return on investment over time as layers of need are peeled back, understood and operationalized. 

As noted in The Innovator's Prescription, intuitive medicine (treatment based on specialist-only understanding) may have defined healthcare's origins, but it will take the entire healthcare village — and the right data and analytics — to usher in healthcare's new century and a new level of success for hospitals and their partners.


Popular posts from this blog

Alternative payment models: Strategies for success

In this edition of DataGen Insights, we look at how alternative payment model participants can ensure their processes and workflows are optimally set up for success. To help, DataGen listed the top three strategies all providers participating in APMs can employ and created a handy checklist to enable maximum returns and reduce financial risk. Please explore our website to learn more about our  products and services .  Download DataGen Insights today .  We hope you enjoy!

Why it's critical for Primary Care First participants to control and understand leakage

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly. To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made. Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate: Nuances classifying care delivered by provider team members: It’s difficult to distinguish

CMMI’s New Enhancing Oncology Model – Deadline Approaching

As the final at-risk period for the Oncology Care Model was closing at the end of June, the Center for Medicare and Medicaid Innovation announced its new Enhancing Oncology Model (EOM). EOM aims to improve the coordination of oncology care, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment.  What is EOM? EOM is a voluntary, five-year model set to begin July 1, 2023. Patients undergoing chemotherapy for the treatment of cancer will trigger six-month episodes of care.  Eligible EOM participants include physician group practices with at least one Medicare-enrolled physician or a non-physician practitioner who furnishes evaluation and management services to Medicare beneficiaries receiving chemotherapy for cancer treatment.  EOM participants are required to implement eight participant redesign activities to drive care transformation in their practice. Examples include the provision of patient navigation, 24/7 access to an appropriate c