Mind the Gap: Addressing Social Determinants of Health - Where to Begin?

Contributors: Wren Keber, Lisa Soroka, with contributions by Matthew Warfield
To learn more about Wren, Lisa, and Matthew, click here.



With all the buzz about social determinants of health (SDOH) across industry headlines, healthcare leaders are no doubt acutely aware of the need to address the non-clinical needs of the patients they serve. SDOH has demonstrated an immense impact on physical and mental health, with factors ranging from food insecurity to companionship for shut-in patients to lack of affordable housing and green space in urban areas. Therefore, appropriately addressing SDOH needs is increasingly cited as a necessary component of successful population health management programs. Yet, oftentimes the steps to move forward can feel complex. 

The goals are to meaningfully engage an appropriate mix of social and human service providers and successfully tackle the challenge of integrating SDOH interventions into the culture of clinical care delivery. So where to begin? If a comprehensive enterprise plan is daunting, we suggest starting with a framework we call “Screen and Refer” that we describe later in this article. We offer six steps every organization can take to begin building such a program: 

1) Understand the Status Quo: When it comes to addressing non-clinical needs, most organizations likely already take some action. However, rather than promote an organization-wide imperative, these interventions are likely positioned at the service line or departmental level. Or, in outpatient settings, actions might be taken on a case-by-case basis as providers uncover patient needs. Finding and highlighting existing connections between your organization and non-clinical community providers – as well as determining which programs actually work – establishes a good foundation upon which to build a true program.

2) Take Inventory of SDOH Needs: It’s important to understand the predominant social needs for the patients you serve. While common needs are largely shared nationally and are capturing headlines, we all know from experience every community is different. Therefore, there will also be needs unique (or more acute) to your specific population. For non-profit hospitals, a logical place to start looking is the current Community Health Needs Assessment (CHNA), which will include demographic and socioeconomic information within each hospital’s service area. Engaging with health systems, hospitals, county, and Federally Qualified Health Centers (FQHCs) clinics and health centers are also a resource to help understand which issues exist in the community, such as service providers with limited funding/capacity (or even excess capacity), or social needs that lack services available to address them.

3) Establish a SDOH Services Directory: Based on knowledge of existing non-clinical providers and services, create a directory to use across program planning, implementation, and operations. Make your services directory accessible to providers and administrators. You will likely be able to build a directory using existing tools, such as customer/provider relationship management (CRM) systems. Then, begin to match known patient needs with available SDOH services to understand where referrals or partnerships will make sense.

4) Understand Referral and Partnership Opportunities: For some communities and organizations, we believe a logical first step is to build a simple “Screen and Refer” program mentioned above. This would first engage providers to adopt generally accepted screenings for patient SDOH needs. Then, armed with the SDOH Services Directory, providers make referrals to known service providers to close gaps.

This program should involve training for providers, selection of a screening tool of the appropriate complexity, integration into existing workflows, and ongoing curation of the SDOH Services Directory. Partnerships over time may provide opportunities to build more robust programs. For example, partnerships with organizations to fund additional capacity, improve service consistency and quality, adopt and integrate new technology, or even incentivize outcomes are all viable and potentially rewarding options.

5) Collect Data to Monitor Progress: As with any meaningful program, an organization needs to be self-aware of its starting point and destination. Identifying markers along the journey will indicate progress. For example, when a “Screen and Refer” program gets launched, a starting indicator of a screening tool is the number of screenings conducted for the appropriate patients. Collecting the output of the SDOH screenings and integration into the medical record is also important. For example, Z codes, included as secondary diagnoses in the encounter document, capture socioeconomic factors impacting health. Capturing Z codes (specifically Z55-Z65) during screening can be the difference between useful and useless encounter data, and the number of Z codes included in encounter data is another indicator of program progress. 

6) Turn Metrics into Action: When it comes to data collection and tracking, most organizations will want to start small. Identifying a few causal metrics, tracking them, and developing actionable responses to undesirable trends is an ideal first step. Moreover, to streamline reporting and visibility at the executive level, every SDOH intervention should be tied to an organizational metric or goal.

For example, a hospital seeking to manage a high readmission rate (the organizational metric) for its Medicaid line of business might integrate a “Screen and Refer” program into the discharge planning process. Two process metrics to measure initial uptake of the “Screen and Refer” program might be percent (%) of Medicaid discharges with a completed SDOH screen and percent (%) of identified SDOH gaps with a resulting referral within five (5) days of discharge. For both, if the percentages do not increase over time, take a look at root causes, such as screening complexity, program resources, social providers’ capacity to accept referrals, external programs funding constraints, and so on.

While there are dozens of models currently being built, tested, and deployed to manage social determinants of health, every organization can get started quickly and effectively with a simple program. Tying program design with financial and operational goals should yield a measurable return on investment (ROI), while SDOH interventions assist non-clinical service providers in the community through steady referrals. We strongly believe the necessary social and human services will benefit the patients you serve.

Contact Lisa at:
[email protected]

Contact Wren at:
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Contact Matthew at:
[email protected]