The pandemic has drawn attention to long-standing health care inequalities due to underlying social determinants of health problems, such as living in food deserts, lack of reliable transportation, and unequal access to care.
However, many health IT folks believe that healthcare provider organizations can use advanced analytics to uncover key insights about their patient populations and take action to ensure equal access to high-quality care for all patients.
Sheila Talton is the CEO of Gray Matter Analytics, a company that provides value-based healthcare analytics as a service. She strongly believes that analytics can help solve SDOH problems.
We interviewed Talton for her expert insights on why SDOH issues are so important and often overlooked, how advanced analytics is one of the important answers to SDOH issues, how organizations can uncover key SDOH insights about their patient populations, And how executives are accountable for analytics can help turn insights into action.
Q: Why are social determinants of health problems such as living in food deserts, lack of reliable transportation and unequal health care so important yet often overlooked?
A sort of. Let’s start with why they matter. Social determinants of health include a range of socioeconomic factors that affect the health of individuals and populations. These include economic stability, education levels, neighborhood and natural environment, access to nutritious food, community and social factors, and access to quality healthcare.
Combined with healthy behaviors—here I’m referring to an individual’s level of physical activity and use of substances such as tobacco, alcohol, and other drugs—social determinants can account for 80 percent of health outcomes. This is quite important.
This is also fairly obvious. After all, how can a person who is homeless, unemployed, without health insurance, and without easy access to quality care be not at high risk for poor health? In this regard, therefore, it is difficult to understand why the impact of social determinants on health has only been recognized in the past few years.
However, there are two fundamental reasons why SDOH has historically not been integrated into healthcare. The first is that under the traditional fee-for-service reimbursement system, providers have no incentive to treat the whole person or perform preventive care.
However, as more providers embrace value-based care—rewarding healthier outcomes and cost savings—they realize the importance of leveraging social determinants to guide care treatment plans and interventions. The second reason SDOH has been overlooked until recently is that suppliers have not been able to access much of this data or analyze it for actionable insights. Fortunately, this is changing.
Q: Why do you say that advanced analytics can be one of the important answers to SDOH questions?
A sort of. Advanced analytics can help providers transform care delivery and approaches around member engagement by integrating information on social determinants. For providers using value-based care models, the insights they gain from SDOH data allow them to proactively influence health outcomes.
Advanced analytics meet the urgent need for providers to identify upstream risk patients and intervene to prevent avoidable care usage costs.
For example, by applying advanced analytics to SDOH data as well as clinical, claims, and historical data, providers can determine which patients are at increased risk for behavioral health problems. Clinicians can then intervene in these high-risk patients to provide referral and treatment options.
An advanced analytics healthcare platform combined with machine-based learning enables healthcare organizations to proactively address physical issues—especially chronic conditions like diabetes and heart disease—as well as behavioral health issues, reducing future healthcare costs and increasing Healthy Equity.
Q: How can healthcare provider organizations demonstrate key SDOH insights about their patient populations?
A sort of. Providers must first ask patients for relevant SDOH details and then ensure they collect all available SDOH data. This requires connecting with relevant community organisations and other third parties to access structured and unstructured data that can be analysed.
Next, providers should use advanced analytics to identify groups of people with common attributes. This enables healthcare organizations to prioritize actions based on the urgency, severity or cost of challenges facing patient populations.
Population data analysis helps providers quickly determine which patients should be targeted for outreach and intervention. Perhaps the analysis has identified several patients who recently missed their annual health visit; providers can then contact these patients to reschedule appointments or offer other meaningful interventions.
We talked about behavioral health earlier. People battling behavioral health problems such as psychosis and postpartum depression tend to use it more than the general population in emergency departments, the most expensive form of health care. Referring these patients to behavioral health treatment options can better meet their needs while reducing costly emergency room visits.
Q: How can executives responsible for analytics at a provider organization help turn insights into action to ensure equitable access to high-quality care for all patients?
A sort of. This is a good question because it touches upon the core issues of translating insight into better care and ensuring equity in healthcare. I am a firm believer that value-based care models will struggle without actionable insights into the whole person backed by SDOH and advanced analytics, and without equal access to quality healthcare for all.
One way provider analytics leaders can turn insight into action is by fostering a collaborative, team-based approach to care in which SDOH and other data can be easily shared and accessed by clinicians and authorized users.
It is difficult to have a successful team-based approach without everyone having access to the same data. In addition to improving outcomes, a collaborative, data-driven approach to care will help providers meet and exceed the requirements of value-based contracts.
Equal access to high-quality care is a major challenge, but one thing provider organizations can do is work with community-based organizations to develop a network of referral services for patients identified through advanced analytics as at high risk and in need of intervention.
These actions can range from arranging rides to medical visits to making referrals to social services agencies for subsidized housing, job training or meal programs. A series of small steps can add up to make a big difference.