Addressing social needs and social determinants of health — what comes next?

Hospitals and health systems are improving value and health equity by addressing the social needs of their patients and social determinants of health in their communities. They are screening patients for social needs and connecting them with resources to support their ability to stay healthy or recover from illness. 

Hospitals also are partnering with payers and other community organizations to improve health and well-being in their communities. More than 90% of hospitals responding to AHA’s annual survey have entered into at least one type of community partnership to address social determinants.¹ And The Value Initiative has numerous examples of hospitals tackling individuals’ social needs and addressing the broader social determinants in their communities. 

Hospitals are doing great work in this space. And as a field, we are making progress. Yet there is still room for improvement, particularly in how hospitals are using data to guide their work and demonstrate the impact of their efforts. 

During an AHA-hosted story slam at The Root Cause Coalition’s National Summit on the Social Determinants of Health, hospitals highlighted the metrics they are using to build the case to address social needs and social determinants, evaluate their progress and determine their next steps.

Cone Health in Greensboro, N.C., shared how it examined its community data to build a case for addressing its patients’ social needs. They found that the community’s history of redlining — the systematic denial of certain services to specific communities (often affecting people of color) — which dates back to 1935, directly correlated to higher rates of substandard housing today. And within those neighborhoods, there continue to be health inequities, including higher rates of respiratory-related illnesses, such as asthma. After making this connection, Cone Health was better able to design interventions and strategies to address these conditions. 

New York City-based NewYork—Presbyterian Hospital, which also participated in the story slam, found that studying the impact its social interventions had on reducing emergency department visits and inpatient stays was helpful as part of its social-needs strategy. 

And Dallas-based Parkland Health (which was one of 10 hospitals selected to address a health equity issue through AHA’s Hospital Community Cooperative) shared how it used geographic data to address disparities among patients with late stage breast cancer diagnoses. After discovering ethnic and demographic differences in cancer rates, Parkland convened focus groups to discover barriers to mammogram utilization. As a result, Parkland worked to create more awareness in the community around mammograms and built an alert into its electronic medical record to identify patients that needed the screening. It continues to refine its mammogram delivery strategy based on both qualitative and quantitative data. 

As you can see, these hospitals needed data and metrics to evaluate their interventions. Other hospitals are tracking health outcomes and assessing patients’ experiences along the way. And, some are measuring the costs that are diverted as a result of their interventions.
 
Capturing data and building out appropriate metrics is not without significant challenges, however, data and metrics are needed to show how interventions improve value and health equity. They help hospital leaders determine where to go next. And they enable us to advocate for solutions at the federal level that make sense — solutions that better align federal dollars with the needs of communities around the country and support the move of payments from volume to value. 

Most importantly, this data will allow all of us to prepare patients and communities around the country to live healthy lives. 

Priya Bathija is vice president of AHA’s The Value Initiative.
 

_{[1] Source: AHA 2017 Annual Survey Data}