Millions of individuals are out of work. Food insecurity is on the rise. Access to safe and affordable housing has declined. Anxiety and depression are at an all-time high due to stress and isolation. While anyone can be infected with SARS-CoV-2 (Covid-19), underserved and marginalized communities are at much greater risk of not only contracting and dying from this disease but also suffering long-term socio-economic and health impacts.

As we look towards recovery from this pandemic, it’s more important than ever for the healthcare community to look beyond the traditional zone of clinical influence and include “life factors” (a.k.a. social determinants of health) as part of their intervention pathways. While social determinants of health data can be difficult to collect and share, it’s imperative to success; both in terms of recovering from this pandemic, as well the ongoing sustainability of value-based care.

First Step is Knowing Where You’re At

One of the most commonly cited barriers to using SDoH data is simply knowing where to begin. Across all of the articles, whitepapers, and get-started tutorials the consensus is that in order to know where to begin you must first know where you’re starting. Provided below is the short-list of important questions for organizations to consider when assessing their ‘starting point” and readiness to take on social determinants of health.

  • Culture
    • How does the organization view the collection and use of SDOH data?
    • What is the level of communication and buy-in from staff?
    • What is the level of cross-departmental collaboration?
    • Are there strong partnerships with the community?
    • How does this align or conflict with other initiatives & priorities at the organization, state, and national level?
  • Leadership
    • Is leadership clear on what problems are being solved and how the information will be used?
    • Are the costs of implementing an SDOH HIT plan well documented and understood?
    • Is Leadership able to clearly articulate how SDoH data will support efficiency and quality improvement?
    • Are there well-defined definitions of SDoH factors?
    • Are there agreed-upon metrics for measuring outcomes and ROI?
    • Does Leadership understand the required staffing changes, both current and future?
  • Operations
    • Does the organization have a general awareness of industry initiatives and resources available?
    • Has the organization assessed what screening/assessment tools are available?
    • Is the organization prepared to change workflows, based on how this might impact established patient volumes, throughput, and staffing levels?
    • Is there a plan on how to use the information collected and with whom this information will be shared?
  • Technology
    • Does the organization understand its data needs?
    • Are the current capabilities and infrastructure sufficient to support SDoH needs?
    • What gaps exist in the data, including availability, quantity, quality, and ability to link to the patient?
    • What are the technical capabilities for tracking applied interventions and their outcomes?

Second Step is Knowing Where to Turn to for Help

Once you know where you are at in terms of organizational readiness, the next step is to do your homework and get familiar with the SDoH landscape, e.g., who are the key stakeholders, trailblazers, etc.? Where are there examples of success? What challenges and struggles did they have that you can avoid? To help get you started, we’ve provided a few helpful links to point you in the direction of organizations that are making headway on this initiative.

Tips to Get You Started

“Start Small – tackling SDoH data can be a major undertaking. Starting small allows you to work out any issues in the workflow, dispel common myths or concerns, and use findings and lessons learned to educate others.” – Office of Disease Prevention and Health Promotion

“Select a Population of Focus – While it is important to have an understanding of all of your patient’s socioeconomic needs and circumstances, starting with a population of focus is a strategic way to pilot and share data findings and lessons learned for further engagement and buy-in. Populations of focus may be determined by the organization’s objectives, by staff availability and workflow alignment, or by project deliverables.” – National Association of Community Health Centers

“Don’t recreate the wheel – Someone has already done the heavy lifting, so just do the homework and leverage existing resources. There is so much out there!” – Yours truely.