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Social determinants of health data can be difficult to collect and share, but it's imperative to success

It's the early days of data sharing and community partnerships when it comes to SDOH, but there are things providers can do now.

Jeff Lagasse, Associate Editor

Data plays a huge role in conducting the business of healthcare, and data surrounding social determinants of health is increasingly important. With reimbursement tied to outcomes, providers need to ensure that patients are receiving the best possible care, and certain social factors can make that a challenge, from lack of housing to inadequate transportation.

The challenge now facing healthcare organizations is that, traditionally, SDOH data hasn't been captured. Most of the data that's recorded during a visit is directly related to the patient's health and doesn't incorporate ancillary factors that can impact well-being. Some SDOH data is captured, but not in a lot of detail.

"The challenge is that providers can't act on this information," said Dr. Lindee Chin, senior director of value-based care at Edifecs."They need to refer to community organizations or social service organizations, and that's not a partnership that's been there for a long time. Patients don't always feel comfortable sharing this information, and they don't know how the data is going to be used.

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"With (providers') contracts being measured on patient outcomes, if they don't understand that this is a factor, this will affect their reimbursement in the end," she said.


The first step in adequately capturing SDOH data is to simply be aware of the different types of data that needs to be captured. Ideally providers should be educated on social issues, health equity and how changes can actually be implemented within the practice.

"Providers have started reading about the topic and looking at their patient population, but they have to start educating themselves on what information to collect, and how to act on that information," said Chin, adding that it may be necessary to see if there are places within the community to which they can refer their patients.

There are a number of factors to consider, and one of the top SDOH challenges that can affect health is food insecurity. If a patient doesn't have access to good food, that can play a big role in developing chronic disease, and patients struggling with chronic disease tend to be costlier to the U.S. healthcare system generally. If a patient is already diabetic, or suffers from heart disease, food insecurity can make the matter worse.

Transportation is another top consideration. If patients don't have access to reliable transportation, they can't make it to their appointments, and their health can decline as a result. Then there's the housing issue.

"The homeless population is a big challenge as well," said Chin. "When they get discharged, how do they manage their condition when they don't have a home? That can be a big issue, finding transitional housing to help manage the disease."


Understanding the importance of SDOH data means little if the information can't be structured in such a way that it can be shared with other organizations. To be truly actionable, a provider needs to be able to transmit the data to a foodbank or social services organization so they can act in a meaningful way for the patients in question. Actionable data is also useful for state agencies that can start collecting the information and analyzing what they need to have in place to cater to their population.

"Because this information is sort of scattered today, a lot of providers are using EHRs to collect their information," said Chin. "From a provider perspective it would be important to incorporate that data into EHRs in a more coherent way. The challenge setting a standard. There hasn't been one overarching standard that says, 'This is the tool I need use.'"

Some organizations have stepped up to take a more active role in social determinants. Chin pointed to The Gravity Project out of the University of California San Francisco, which aims to develop use cases related to documenting SDOH data on screening, diagnosis, treatment and population health management. The project, which started in May, focuses primarily on food insecurity, housing stability and transportation access.

Such initiatives, along with community-based partnerships and innovation projects proposed by the Centers for Medicare and Medicaid Services, are exploring different ways to make SDOH data sharing a more feasible reality.

"It's teamwork," said Chin. "No single provider can tackle it."

What a provider can do, however, is pursue more formal contracts with community organizations regarding how SDOH data needs to be shared. Luckily, said Chin, pursuing such strategies isn't capital-intensive.

"It's more of a resource and time commitment," said Chin, "identifying resources within an organization that can capture this information. Depending on the provider organization and their staffing model, they might have to look at creative ways to make it work and how to incorporate it into their existing workflow. Otherwise it's an extra burden.

"Because this is becoming more and more of a focus, hopefully more tools with be created," said Chin. "As standard bodies start defining how this information should be captured and transferred, hopefully it will become even more seamless. It takes time for that to happen. But it's not going to go away. These factors play into outcomes, so if you don't affect those factors you're not going to affect the outcomes."

Twitter: @JELagasse

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