Healthcare data expert Mohamed Humaidi, senior vice president of data and analytics at the New York and Florida-based health coordinator CareAbout, broke down how clinical practices and health systems can enhance and streamline the complicated processes of identifying and reaching vulnerable patients and how the company is using a new tool to help them do it.

Innovaccer, a health data platform vendor, launched the tool SDOH Explorer. CareAbout is using it to aid healthcare stakeholders in analyzing, comparing and monitoring the impacts of social determinants of health on patients. 

Kanav Hasija, cofounder and Innovaccer's chief product officer, said the tool's customized dashboards demystify the areas where health equity could be improved and benchmark users' performance nationally.

He explained how the tool has been incorporated into practice. For example, rebranded as the County Health Report Card, the tool integrates SDOH data right into patient records and workflows.

"By utilizing this tool at the county level, ACOs and other VBC organizations can gain valuable insights into patients' needs and challenges, enabling them to deliver holistic and equitable care," added Hasija.

Hasija and Humaidi also discussed the daily challenges health systems face to successfully address health equity, and how healthcare technology innovations like SDOH Explorer can seek to tackle them. 

They pointed to a lack of standardized SDOH metrics, inconsistent data and measurement practices, inaccurate risk prediction for individual patients, inadequate screening tools to track SDOH, and failure to consider SDOH when calculating risk pose significant challenges to health systems' efforts to extend care delivery. 

Because health systems do not typically manage social referrals in a single platform, collecting data at the point of care is not always feasible with clinical responsibilities. SDOH screening can also add to a provider's digital burdens during appointments. 

While electronic health records are crucial, "they often lack the capability to easily integrate or exchange data with diverse sources, even among EHRs from the same vendor," Humaidi said. 

By collaborating with Innovaccer – a good example of cross-sector coordination – Humaidi said CareAbout aims to integrate a data layer that can help organizations effectively address the SDOH-related needs of patients. He further explains the impact to health equity.

Q. What are some examples of how accountable care organizations and other value-based care organizations can use SDOH Explorer at the county level to understand patients’ needs and challenges?

Humaidi: To illustrate the impact of such tools, let me share an example from my experience. In the years 2015-2017, I worked on the Home Health Outreach Program in New York, specifically for Medicaid beneficiaries. 

A Health Home, a collaborative group of healthcare providers, worked together to ensure patients received the necessary care and services for maintaining good health. Enrolled patients were assigned a care manager who helped develop personalized care plans, aligning services to improve their wellbeing.

Our program focused on enhancing the process of identifying and stratifying vulnerable patients, aiming to enroll them in suitable programs. By providing targeted interventions and services, we were able to effectively support the most vulnerable individuals. 

Through the program, we achieved a 15% improvement in outreach performance from 2015 to 2016, and an additional 8% improvement from 2016 to 2017.

By leveraging a tool like SDOH Explorer, the impact of such initiatives could be significantly multiplied. County-level data empowers healthcare providers with a detailed understanding of social determinants, facilitating better identification and documentation of SDOH insights within specific populations. This, in turn, will enable more informed decision-making and improved outcomes for patients.

Q. How do clinicians integrate SDOH data into clinical workflows and patient data to improve care access?

Humaidi: Clinicians can integrate SDOH data into their clinical workflows and patient data to improve care access by utilizing various methods. 

First, they can embed SDOH assessments within the digital tools that physicians commonly use during in-patient encounters. This allows for a streamlined process of collecting relevant SDOH information directly within the existing workflow.

Additionally, clinicians can send assessments to patients via email or text, enabling the collection of SDOH data outside of the clinical setting. Once collected, this information can be seamlessly integrated back into the patient's EHRs to eliminate the creation of separate data silos and ensure that the relevant data is readily available within the patient charts.

To further enhance the integration of SDOH data, healthcare organizations can leverage healthcare-contextualized digital tools. These tools can write back the collected SDOH data directly to native EHRs, ensuring that the information is easily accessible and eliminating the need for manual data entry or data transfer between systems. Such tools can also generate insights from SDOH data, allowing for anytime-anywhere access to valuable information.

Furthermore, establishing centralized coordination between primary care providers, community-based organizations and social services is crucial. This coordination helps to effectively close referral loops and maintain transparency in addressing patients' needs. It enables a seamless flow of information and resources between different stakeholders, leading to improved care access.

To ensure the effectiveness of CBOs in fulfilling patients' needs, healthcare organizations can track their engagement and establish incentive models. This encourages a proactive and responsive CBO network, contributing to better care access and outcomes for patients.

By leveraging a data and analytics platform with prebuilt integrations with leading health IT systems and vendors, healthcare organizations can clean, standardize and unify all healthcare data sources. This includes clinical, claims, labs, pharmacy, SDOH and device data. 

By having a centralized and unified platform, healthcare organizations can improve collaboration, achieve native interoperability and accelerate innovation in care delivery. This approach provides a scalable foundation for leveraging SDOH data and improving care access in a sustainable and future-proof manner.

Q. How has access to socioeconomic factors, such as housing, access to food and transportation and social connectedness improved the organization’s ability to address gaps in care?

Humaidi: Access to socioeconomic factors such as housing, food, transportation and social connectedness, has significantly enhanced organizations' ability to address gaps in care. This improvement can be attributed to several key factors:

1. Coordinated workflows: By utilizing interoperable technology, organizations can establish streamlined and transparent communication channels between network providers, patients and CBOs. This facilitates seamless collaboration and enables the fulfillment of patients' needs.
2. Advanced predictive analytics: Leveraging sophisticated analytics tools allows organizations to generate valuable insights into patient care. These insights can be used to improve outcomes, manage high-risk populations, drive cost savings and foster stronger relationships with patients.
3. Tracking SDOH trends: Organizations can monitor and analyze SDOH trends across the community. This helps in identifying areas of need and measuring the impact of interventions by providing detailed insights on screenings and referral outcomes.
4. Scaling initiatives: By employing data-rich insights, organizations can scale initiatives from a subset of patients to broader populations within a region. Geo-targeted interventions guided by these insights enable targeted support and resources where they are most needed.

For the Health Home Program, we utilized socioeconomic data to optimize outreach and clinical operations. By understanding the specific socioeconomic factors affecting each patient, we could create tailored daily call lists and assign the appropriate health home care coordinators. 

This led to improved reconciliation and billing processes, benefiting our patients. Thanks to these insights, we were able to provide services to approximately 88% of the patient population, addressing gaps in care more effectively.

Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.