Social Determinants of Health Summit 2024
Elements of Successful, Replicable Collaborations on SDOH Initiatives

What standardizations can EHR vendors implement or improve to simplify the closure of referral loops for CBOs?

• Interoperability & data standardization: EHR vendors must prioritize interoperability and standardized data fields to facilitate seamless referrals across systems, enabling CBOs to manage and track client information effectively within varied healthcare ecosystems.
• Resource and capacity support for CBOs:To close referral loops successfully, EHR systems need to be user-friendly and offer tailored support, especially as CBOs often face limited resources, variable technical capacities, and differing data requirements from multiple funders.
• Enhanced privacy & trust mechanisms: Establishing robust, compliant privacy protocols and building trust among CBOs, patients, and healthcare providers are essential to support data sharing, protect sensitive information, and encourage consistent use of referral tools and platforms.

What is the weakest link within the data-aggregation and insight-generation processes, and how can that be effectively addressed?

• Gaps in real-time data & feedback loops: Delays in data entry and feedback, coupled with insufficient mechanisms for timely data sharing, prevent effective follow-up and limit the accuracy of insights, suggesting the need for streamlined, real-time data integration and communication pathways.
• Lack of standardization & interoperability: The absence of standardized data fields, metrics, and interoperability across EHR systems hinders data aggregation and insight generation, requiring a unified approach to ensure consistent and comparable data.
• Incentive & resource limitations: Insufficient financial incentives and resources for CBOs and healthcare providers limit their capacity to contribute to data documentation and aggregation, underscoring the need for financial models that support their participation in these processes.

Which metrics should organizations track to solidify internal alignment and long-term SDOH investment?

• Short- & long-term impacts: Organizations should focus on both short-term, quantifiable returns (e.g., reduced ED visits, intervention counts) and long-term outcomes (e.g., quality-of-life improvements, social impact metrics) to ensure sustainable SDOH investment.
• Engagement & access: Tracking patient engagement rates, accessibility to resources, and closed-loop referrals highlights immediate needs and barriers, helping organizations improve SDOH program effectiveness by ensuring resources reach intended individuals.
• Financial and ROI-related metrics: Financial viability metrics (e.g., Return on Health, per-member-per-month costs) emphasize the importance of demonstrating both direct and indirect cost benefits to secure continued funding and organizational buy-in for SDOH initiatives.

What are the best practices for IPV screenings during the visit and during follow-ups that promote comfort, confidentiality, and access to needed resources?

• Trauma-informed & culturally sensitive screening approaches: Implementing trauma-informed care (e.g., using educational videos on relationship safety, discreet conversations when a partner is absent) allows patients to discuss sensitive issues without feeling accused or vulnerable. For instance, training staff to ask open-ended questions privately and to use non-accusatory language can create a safe space that encourages honest disclosure.
• Discreet & accessible resource provision: Providing patients with discreet materials, like small cards with contact information for IPV support services, normalizes the distribution of IPV resources without relying on disclosure. Healthcare providers could hand out these resources universally at discharge, similar to educational packets for chronic conditions, ensuring all patients receive support tools without feeling singled out.
• Privacy & confidentiality in screening methods: Maintaining patient privacy through private, in-person conversations or text-based options (avoiding digital logs in shared records) helps protect individuals from potential risk while ensuring that those who disclose abuse can receive immediate support and referrals.

What are quick, affordable changes that providers can make during patient interactions that have the most positive impact on health equity and inclusion?

• Enhanced patient communication & cultural competency: Providers should train staff to use straightforward, culturally relevant language and reduce clinical jargon to establish trust. Additional DEI training focused on local community demographics, such as regional linguistic preferences, can make interactions more sensitive and responsive to diverse patient needs.
• Peer & community-based support: Healthcare organizations should hire community health workers and peer mentors from cultural and socioeconomic backgrounds similar to their patient populations and empower these team members to support patients during and after appointments. Specifically, organizations can implement “peer follow-up” programs, where mentors connect with patients post-visit (particularly in high-need areas like addiction support and post-incarceration transition) to encourage health engagement outside of clinical settings.
• Accessible information & self-service tools: Clinics should provide simple, user-friendly resources for accessing support services, such as cards with QR codes that link to public health directories and provide easy-to-understand instructions. Self-service tools (e.g., private, tablet-based surveys, nutrition-related resources in community clinics) offer patients privacy and autonomy while providing healthcare staff with valuable, actionable insights into patient needs.

What Should Provider Organizations & Vendors Do Going Forward?

To ensure successful SDOH programs, provider organizations need to highly value SDOH initiatives as part of their overall value-based care strategy and ensure stakeholder buy-in. Additionally, provider organizations have the responsibility to drive adoption with needed groups, such as CBOs and ACOs. Vendors need to articulate the value of SDOH programs to the provider organizations and offer strategic guidance on how to most effectively execute SDOH efforts. Together, provider organizations and vendors should bring CBOs in as partners throughout the entire SDOH collaboration to better identify community needs and bridge the technology gap between providers and CBOs.

Collaboration #5: Communicating with Maternal Health Patients Between Appointments to Prevent Delivery-Related Complications 

Executive summary: In the US, it is common for women to die during or after pregnancy when they are in low-resource settings with limited access to care. There are also other disparities in maternal care. To address these issues, the collaborators in this case study implemented a comprehensive maternal health program that provides personalized care and continuous support for prenatal and postpartum patients. Get Well’s product was used to engage patients via texts and phone calls, and Findhelp’s product was used to connect patients to community resources.

Outcomes: LifeBridge Health has reported increased patient satisfaction and improved patient-progress tracking due to streamlined communication with Get Well and Findhelp, leading to better health outcomes. Healthcare providers can now track patient progress more efficiently and intervene in a timelier manner, contributing to a 23% reduction in preterm deliveries, a 23% decrease in NICU admissions, and a 41% reduction in baby length of stay. These improvements are linked to enhanced symptom checking, kick counting, and early preeclampsia identification. Despite initial concerns, there has been no increase in unnecessary appointments, as patients trust navigators and adhere to healthcare instructions more consistently.

Collaboration #8: Giving Hope to Youth Through Mental Health Support

Executive summary: Following the onset of the COVID-19 pandemic, feelings of hopelessness (as measured by the CDC) increased significantly among high school students in the United States. In 2021, the CDC reported that more than 40% of students felt persistently sad or hopeless. Due to this increase and the fact that caring for a child with a behavioral health condition is a significant expense for families, the collaborators in this case study created a preventive program that identifies and assists at-risk youth and families with SDOH needs.

Outcomes: In the pilot program, 81% of the targeted youth activated their accounts on the platform, enabling early identification of those needing mental health intervention. Screenings revealed that 20% of these youths had low hope scores, with over half not previously identified through school screenings. Additionally, 30% of the youths had caregivers with unmet social needs, and they were then directed to resources for assistance with housing, utilities, and food insecurity. The program aims to reduce behavioral healthcare costs by $2.5–$3.7 million within a year by decreasing incidents of self-harm, ER visits, substance abuse, and inpatient stays among the population of 100,000 youth.

Collaboration #10: Addressing Social Health Disparities Among Medicaid Members

Executive summary: 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.

Outcomes: As of August 2024, PM Pediatric Care has screened over 19,000 families and placed over 9,500 referrals. Additionally, more than 420 provider groups outside of PM Pediatric Care have joined the SDoHPIP, completing 40,700 social needs assessments and making 34,500 referrals for Elevance Health’s Medicaid members. Elevance Health and Findhelp are also enrolling CBOs into a network of trusted partners to provide providers with community resources for patient referrals. This initiative aims to enhance the support network available to healthcare providers and their patients.