As the healthcare field further recognizes the critical role that socioeconomic factors play in patients' well-being, it’s important that providers and healthcare institutions adopt a holistic approach that addresses SDOH.   DataGen’s Mandi Diamond, senior practice transformation advisor, breaks down the key reasons for understanding and measuring SDOH and provides additional healthcare delivery insights. Read on for expert medical practice consulting advice.   Understanding social determinants of health   In recent years, healthcare practices have been held accountable for collecting SDOH data. This metric includes race, ethnicity, language, socioeconomic barriers and even personal circumstances, like family structure and sexual orientation/gender identity.  The more practices expand their data collection efforts, the easier it is to understand patients' backgrounds. This allows practices, specialists and community resources to build stronger, more tr...

Z codes that document patients' non-medical needs are rarely used and often misunderstood. Yet they’re vital to address social determinants of health, which are responsible for 80% of a person's health outcomes. New developments make it easier to incorporate Z codes into an organization’s health equity strategy. These include patient e-screening, leveraging an enhanced Community Health Needs Assessment, use of robust social risk intelligence data and new efficiencies that capture insights from these sources and make them actionable. By using a combination of "push and pull" strategies, health systems can start these efforts now. But first, a brief introduction to Z codes and why they're important. What are Z codes and why are they important? Z codes are a subset of ICD-10-CM diagnostic codes to document a person's SDOH, defined by Healthy People 2030 as "the conditions in the environments where people are born, live, learn, work, play, worship and age th...

Not owning a vehicle in New York City has negligible impact on a person’s health. Not owning one in a rural area — or even a booming metropolis like Nashville that lacks a diversified public transportation system — can be life-threatening. This tale of two cities suggests that transportation, perhaps more than any other social determinant of health, illustrates the link between ZIP code, disparities and health outcomes. The importance of transportation Missing medical appointments due to lack of transportation is a stark example of how SDOH can directly impact health outcomes. The ability to get where and when you need to is also connected to other social determinants of health domains such as finance, food and housing. However, one study found that transportation is found in fewer SDOH assessment tools (66%) than any other metric besides social and community context (61%) and physical activity (33%). Addressing transportation inequality begins with knowing how it impacts populations ...

Why is healthcare so confusing? Navigating its complexity is the last thing a patient needs when their health is on the line. Yet, this confusion happens every day — even to career healthcare professionals who understand how the system works. Many startups have been launched to "fix healthcare" due to a founder's personal negative experience. The Health Resources and Services Administration defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.” Without healthcare literacy, navigating the complexities of the healthcare system becomes impossible. It is the foundation of patient self-advocacy. Addressing health literacy goes to the heart of literacy itself. It has as much to do with how information is presented as how it is understood. "Health literacy represents a lot of opportunity on the healthcare industry side. We can do a lot better than...

It’s 5 p.m. on a Tuesday. You’re exhausted and still need to pick something up for dinner. The nearest grocery store is 15 miles away, and the only thing closer is a convenience store with higher prices and fewer healthy options. This is what it can be like to live in a food desert  — one of several contributing factors of food insecurity. Food insecurity and limited or uncertain access to adequate food impacts millions of Americans each year. And the pandemic only compounded access and affordability issues that drive food insecurity like irregular income, unemployment and disability. Add to this heredity’s influence, race and ethnicity and you have a very complex picture of food-related health issues in 21-century America. While most social determinants of health lay outside of healthcare’s circle of influence, they create conditions that erupt inside its circle of treatment. In most cases, the healthcare industry faces acute to downstream effects in the form of imprope...

The most immediate point of intersection between hospitals and consumer financial risk is the inability of patients to pay their medical bills. This is changing as the role of hospitals in meeting social determinants of health (SDOH) expands. Low incomes and poor health outcomes are linked across multiple conditions and stages of life. The short- and long-term risks of financial security are amplified for providers and patients, given just how close so many in the U.S. are to economic shocks they cannot cover or rebound from: A Federal Reserve survey found that 36% of adults could not pay cash to cover a $400 emergency expense ; even those who could cover the expense might tap savings or a credit card to meet the immediate need (2020). Race-related outcomes are worse: nearly 40% of employed Black or Hispanic adults in the same survey reported that a $400 emergency expense would make it harder to pay other bills, compared to 18% of employed white adults. This can create ...

In this edition of DataGen Insights, we take a deep look at the important role of data analytics in understanding health outcomes. Read more to learn how hospitals are using data to guide their social determinants of health strategies. DataGen's newsletter is designed to provide relevant healthcare insights to providers and associations. Please explore our website to learn more about our products and services .  Download DataGen Insights today .  We hope you enjoy!

Can ACO REACH help CMS and providers achieve the unmet goals of prior alternative payment models? If so, a stronger focus on equity, provider leadership, accountability through risk and evaluation may make the difference. Announced Feb. 24, ACO REACH — Accountable Care Organization Realizing Equity, Access, and Community Health — is CMS' newest voluntary APM. Robust resources and capabilities will be needed to navigate its requirements. As highlighted in a recent CMS webinar , ACO REACH is the first APM to launch following a Strategy Refresh by the Center for Medicare and Medicaid Innovation. ACO REACH aligns with the CMMI objective of driving accountable care to improve cost and quality and will replace the current Global and Professional Direct Contacting program, effective Jan. 1, 2023. CMMI encourages current GPDC participants and new entrants to apply, noting that selection criteria and performance monitoring will be more stringent. This blog highlights key differences bet...

All forward-thinking hospitals understand the role of social risk in providing effective, equitable and efficient care. In many ways, hospital objectives align with those of social risk assessment. Both help to distinguish acute from long-term needs, identify underlying contributors to poor outcomes, and, wherever possible, help minimize or completely prevent more serious interventions. Six social risk factors and their drivers Social risk is a measure of vulnerability as defined by specific social determinants of health. DataGen uses the following six SDOH categories. Social Determinants of Health Category Defined by Individual risk drivers Community risk influencers Digital Access, affordability and literacy Competency Resources Finance Strength, resources and resiliency Financial assets, liabilities and opportunities Income, cost of living and opportun...

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 ...

Partnership has always been essential to achieve healthcare's aims. And where there's a will — and a pandemic — there's a way. To find the way , hospitals and community-based organizations must partner in new ways to incorporate social determinants of health into patient care improvement efforts. Rich new SDOH data sets can supercharge the design, implementation and evaluation of SDOH initiatives as providers are expected to assume more responsibility for outcomes related to non-clinical factors.  The impact of social determinants of health  The pandemic resurrected a statistic that has been around for some time: 80% of health outcomes are based on social determinants, with only 20% dependent on clinical care.  People naturally understand it is harder for someone to manage their diabetes without access to affordable, healthy food. Through the federally-required Community Health Needs Assessment process, hospitals understand local need, but many do not yet know how to shif...