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SDOH Points of Light 2024: Recognizing Partnerships That Creatively Address SDOH Needs & Improve Whole-Person Care Report Cover Image

Case Study

SDOH Points of Light 2024: Recognizing Partnerships That Creatively Address SDOH Needs & Improve Whole-Person Care

01 October 24 | Benjamin Cassity and Kyle Chilton

An individual’s health is determined by a variety of factors, including socioeconomic factors that aren’t treated or monitored within hospitals and clinics (e.g., housing, food access, language barriers, transportation). When patients struggle with these social determinants of health (SDOH), they are more likely to experience compounding health issues that require longer recovery times, increasing costs for both themselves and the healthcare system. Healthcare organizations, payer organizations, community-based organizations (CBOs), government organizations, and HIT vendors can partner to address communities’ SDOH needs and prevent patient conditions from worsening. KLAS’ SDOH Points of Light recognitions celebrate such partnerships’ successes—or “points of light”—in transforming patient and community care. 13 partnerships were given a 2024 SDOH Points of Light recognition, and their strategies and outcomes are shared in this report to highlight what is possible with deep collaboration. This Executive Insights section provides a high-level summary of the challenges the honorees tackled, the outcomes they achieved, and key lessons learned on the journey (see last page); the full report provides an in-depth case study of each collaboration.

Patients with complex care needs are expensive for healthcare organizations to treat; they require more intensive care, and some patients overutilize resources when they are repeatedly readmitted to the hospital. To reduce preventable readmissions, the collaborators in this case study worked together with clinics and community resources to save on costs and align their approach to addressing patients’ social needs. They achieved their goal by using Lightbeam Health Solutions to identify underlying social problems and enhance patient engagement.

Saint Peter’s University Hospital did not have an established SDOH screening process, making it difficult to track and address patients’ SDOH needs. So they implemented screenings and worked with their vendor partner, Lightbeam Health Solutions, to synthesize patient data and create tailored care plans for high-need patients. This data was then shared with Healthier Middlesex to follow up with the patients and connect them with community resources.

Elevance Health and Findhelp partnered to offer the Social Drivers of Health Provider Incentive program (SDoHPIP) to help standardize the identification of social health disparities among Medicaid beneficiaries (thus standardizing the process of connecting those beneficiaries to community resources) and to offer financial incentives to both providers and CBOs to ensure they can close the loop on needs identification and resource referrals. Using this program and the Findhelp platform, PM Pediatric Care has been able to use their access to Medicaid beneficiaries to connect children with local community resources to help strengthen their social health.

K2 Collaborative - Payer Provider Accountability Consulting

K2 Collaborative - Payer Provider Accountability Consulting

What Is the K2 Collaborative (formerly Payer/Provider Initiative)?

K2 Collaborative - Payer Provider Accountability Consulting

K2 Collaborative - Payer Provider Accountability Consulting

What Is the K2 Collaborative (formerly Payer/Provider Initiative)?

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