Social Determinants of Health Summit 2023

Framework for a Successful SDOH Program

Before the summit, KLAS met with a steering committee that helped create an initial framework for how to build and optimize an SDOH program, to be presented at the summit. At the conference, participants worked in small groups to share feedback and critique all aspects of the framework. KLAS has used that feedback to create a final version of the framework, detailed below.

General Best Practices from Summit Participants for Building and Optimizing an SDOH Program

The following overarching principles will help organizations build and administer a solid SDOH program. Recommendations for specific pillars of the framework are detailed in the next section.

1. Prioritize strong governance to assess SDOH program readiness and rollout processes. Decide up front what needs you are targeting, how to maintain patient privacy, ways to make SDOH program services and practices equitable, and so on.
2. Get a full picture of the technology you have in place and will need to implement to support all pieces of your SDOH program.
3. Turn to the expertise of other organizations and CBOs that have successfully administered SDOH programs. They can also be useful for benchmarking your own success. A good starting place is the organizations listed in later sections who participated in the 2023 SDOH summit.
4. Join national committees and other organized efforts aimed at furthering SDOH programs, standardizing processes, and more broadly addressing systemic challenges.

Governance and Prioritization

Note: Based on insights shared by summit participants

Best Practices

1. Define the care team (e.g., determine whether it includes members of CBOs and external clinicians).
2. Identify top regional CBOs to collaborate and build relationships with.
3. Identify regional CBO capacities as well as technological capabilities.

Additional Recommendations

Utilize key technologies that support collaboration with CBOs:

• Use a unified solution for the whole multidisciplinary care team (including CBOs)
• Use a care-gap tracker

Consider processes that increase patient trust:

• Consider motivational interviewing—i.e., incentivizing patients to complete evaluations
• Train care managers, social workers, and clinicians on how to provide trauma-informed care
• Create documentation that patients can review to learn how assessment data will be used and what resources they will have access to

Determine methods for supporting patient access to assessments and, ultimately, social resources:

• Facilitate multiple channels for completing assessments (e.g., phone, telehealth platform, website)
• Set up self-guided reporting and access tools to the referral network, all with a human-centered design
• Allow patients to determine how they would like to be contacted
• Work with schools and social care centers (common places where needs are reported) to connect with patients and identify needs
• Implement tools that protect patient privacy and ensure appropriate, role-specific access to data by caregivers and social resources

Data Aggregation

Note: Based on insights shared by summit participants

Best Practices

1. Collect assessments at the point of care.
2. Use open-ended questions in assessments to elicit greater detail.
3. Standardize assessments across organizations to improve data sharing and analysis.
4. Use internal governance protocols to determine appropriate access (including time range of access to data) and security requirements.
5. Train interviewers on how to collect assessments while maintaining safety and patient dignity.
6. Assign resources to normalize incoming data feeds so assessments can easily be matched to patients.
7. Use an enterprise data warehouse to bring together data from different channels and store it for easy analysis.

Additional Recommendations

Use assessment modules tailored to the focus of your program (as decided during the governance process), such as the following:

• PREPARE Screening Tool
• AHC
• Custom in-house assessments

Integrate relevant publicly available data sets to identify at-risk patients, such as the following:

• CMS
• Census data
• County records
• Local community data sets

Integrate relevant retail and other data sets, such as the following:

• Experian
• FinThrive (TransUnion Healthcare)
• LexisNexis
• Other data brokers
• Clinical data
• Third-party app patient data
• Claims data
• Public health data

Analysis & Insight Generation

Note: Based on insights shared by summit participants

Best Practices

1. Use governance processes to determine how best to represent and share insights with caregivers and CBOs.
2. Use the defined KPIs of your program to guide analysis.
3. Leverage technologies that support quick, effective data analysis and clear guidance on next steps.

Additional Recommendations

Use technologies that generate insights & facilitate predictive modeling for use in the SDOH program, such as the following:

• Drill-down dashboard to show population-level insights
• Predictive analytics drawing on demographics information to inform clinicians at the point of care
• Analytics that suggest interventions based on data
• Patient intake solution that collects patient contact preferences and permissions for service requests
• Predictive analytics and AI to identify regional patterns and future demands on SDOH program
• Benchmarking tool that facilitates regional comparisons

Ensure you have all needed functionality for the social care record:

• Comprehensive view of individual’s SDOH history, including assessments
• Electronic master patient index to merge data records
• Compliance with HIPAA and current security standards
• Ability for patients to opt out of SDOH program

Utilize data visualization tools and methodologies aligned with your program’s goals, such as the following:

• Geospatial analysis reporting
• Population trending reporting
• Market profiling for different types of patients
• Visualization tool that integrates with clinician documentation solution
• Integration with referral network to share needed data

Action on Insights

Note: Based on insights shared by summit participants

Best Practices

1. Leverage CBOs that have built trust or can build trust with patients and can establish appropriate communication channels.
2. Work directly with patients to overcome barriers like health literacy and technology challenges
3. Identify whether patients want intervention through patient engagement tools.
4. Build a relationship with key CBOs, including holding ongoing meetings and keeping lines of communication open. You may also want to coordinate agreements for sharing financial resources.
5. Connect your directory to 211.
6. Create a governance committee responsible for managing relationships with CBOs and closing the loop on referrals.
7. Connect to existing support networks within the region.
8. Provide incentives to patients for completing assessments and contacting CBOs.

Additional Recommendations

Consider needed capabilities for CBO network referral and coordination, such as the following:

• Use a directory of community-based resources and what benefits they provide
• Ensure the ability to send electronic service requests
• Ensure the ability to provide real-time details on resource availability at key CBOs
• Facilitate closed-loop service requests (i.e., bidirectional communication between the healthcare organization and social care resources)
• Integrate with community-based support groups that address mental health needs

Leverage tools that can support individual patients in social care

• Provide patient education for social health needs
• Measure patient satisfaction with social care resources
• Set up communication and/or integration with patients’ primary care providers
• Use patient engagement technology to track closure of care gaps
• Use transition-of-care tools that support SDOH referrals

Make sure to account for the most common community resource needs in your region, such as the following:

• Transportation
• Food insecurity
• In-home care (private duty)
• Governmental social service support
• Childcare
• Mental health resources

Impact Optimization

Note: Based on insights shared by summit participants

Best Practices

1. Train patients to use tools that help them get access to resources and share feedback, and integrate those tools with organizational analytics solutions to facilitate real-time tracking and dashboards.
2. Collaborate with neighboring organizations and government entities to regionally standardize KPIs for SDOH.
3. Connect with peers to support connectivity and standardization so individuals can be identified across organizations in a region.
4. Remove barriers by working through trusted contacts, leveraging social workers, increasing cultural competency, and using bidirectional CBO referrals as well as language services.
5. Follow up with patients to assess adherence with recommendations (e.g., care plans).
6. Leverage value-based reimbursement models.
7. Share resources with nonprofits.
8. Communicate with payers to identify resource opportunities for CBOs.
9. Enable patient empowerment by making data accessible to patients.

Additional Recommendations

Establish clinician-focused tools and practices

• Provide a communications tool that can be used across the care team
• Leverage most current FHIR and USCDI standards
• Facilitate clinical access to de-identified data for research

Prioritize tools that enable patient tracking and CBO collaboration, such as:

• Real-time resource utilization tracking
• Real-time tracking data for social care–related spending on patients
• Financial tools for CBOs to track costs and facilitate revenue-sharing with providers

Measure and report on outcomes

• Track program success measures
• Track the financial ROI (total cost of care/whole person health)
• Measure patient satisfaction with social care services, including patient-recorded outcomes and stories
• Track acute care utilization by target demographics
• Provide an executive dashboard to track key performance indicators

Panel Discussions

Panel 1: Financing an SDOH Program

Participants

Summary

Provider organizations have often struggled to clearly demonstrate an ROI that is scalable to other programs. Through this panel, KLAS hoped to bring various types of organizations together to talk through funding for their SDOH programs, with the goal of learning how to make the work more sustainable.

The panel discussion revealed that most large provider organizations have leveraged grants to stand up key technology, such as resource networks. However, ongoing funding is often more problematic. Each organization has focused on tracking difficult-to-track ROI measures. Several organizations, such as HCA Healthcare and United Way, have sought to identify places where spending is high and to funnel money to programs that would decrease spending. For example, increasing spending on early childhood education can help decrease the number of students in special education and thus decrease associated costs. HCA Healthcare identified high-cost utilizers in rural locations and paid for medications internally. Even though Castell noticed a slight decrease in cost PMPM, they admitted that by starting with community engagement, they also increased costs because they were discovering additional needs. OCHIN pointed out that by providing funds to those who are gatekeepers for clinicians, they can keep clinicians operating at the top of their licenses instead of screening people and their needs.

To find the resources necessary to drive SDOH work, organizations had to put forth a multifaceted effort to evaluate funding from multiple sources, including the following:

1. Grants (typically deployed for less resource-intensive work, such as standing up a referral network)
2. Internal funding (typically done by large organizations attempting to decrease utilization by focusing on upstream challenges) (e.g., paying for medications in low-income areas)
3. Charitable donations (typically leveraged by CBOs)
4. Contracting with payers to reimburse for focused initiatives (e.g., paying for diabetes medications in rural settings)

All organizations have worked to build teams responsible for identifying and tracking the efforts of different social initiatives at the organizations. This has typically led organizations to fund other initiatives, such as unique community partnerships that help pay for medications or fund CBOs that meet needs like providing food security. Below are the discussed key action items to improve funding access or drive outcomes:

• Broaden the definition of ROI to include measurements of community changes (e.g., funding low-income housing, tracking homelessness in the area)
• Payers should reimburse high-cost patients for medications in rural areas
• Provide funding for more resources to proactively identify community needs before challenges become acute
• Focus on upstream efforts (e.g., education initiatives, programs to help avoid relocation of people)
• Develop initiatives that pay based on success in key metrics
• Set up governance programs to address SDOH as a strategic business initiative

Ultimately, each organization is nascent in their journey of how to fund their SDOH program, but all are committed to increasing the impact and sustainability for their communities. Participants in this panel encouraged other organizations just starting on their journey to join collaborative communities that are focused on SDOH initiatives, facilitating faster communication around successes and sustainability.

Panel 2: Successful SDOH Metrics

Participants

Summary

Many provider organizations have yet to clearly identify essential KPIs for their SDOH programs. Ultimately, what gets measured is what organizations focus on. Through this panel, KLAS brought several provider organizations and a payer organization together to discuss how to track the success of their SDOH efforts.

During the conversation, all three participants spoke about the challenge of getting data from multiple systems into a single system in order to make connections. Partly due to a regulation that requires reporting on the percentage of customers who receive an SDOH screening, all participants focused on integrating data to report on that metric as a first step. As they addressed this initial challenge, they ran into others, such as:

• Matching clinical and non-clinical data
• Finding and ingesting external data on patients (zip code and social vulnerability scores)
• Finding an analytical resource to check and analyze data
• Identifying resources to conduct screenings (as nurses and physicians have limited bandwidth)
• Lack of governance to drive organizational strategy
• Lack of engagement from executives to provide ongoing resources beyond the initial investment

Organizations worked through the challenges in a number of ways. Ultimately, all agreed they needed to initially establish organizational governance that allowed them to identify passionate participants and enlist them in the work. The governance committee could then help to address challenges. Below is a list of solutions they discovered as they worked toward successfully measuring and tracking SDOH initiatives.

• Use front office staff to screen for needs, connect patients to SDOH resources, and track metrics—alleviating the burden on clinicians at the point of care
• Create a way for patients to self-screen, and launch a marketing campaign to connect patients to the link to complete the screening
• Connect SDOH data to care managers as essential data so they can engage patients holistically
• Use analytics to demonstrate the impact SDOH work has on HCAHPS scores to get buy-in from the C-suite
• Create a dashboard that tracks screenings over time
• Align the SDOH committee with health equity and social governance to increase the visibility of the work
• Have the governance team first build the organization’s structure; then identify key processes that need to happen and leverage technology to track processes and report on outcomes

Even though most panel participants are still evolving their own measurement tools, they have all made efforts to track and report outcomes on impact metrics, including percentage of members screened, number of SDOH gaps addressed, FTEs and resources invested in the program, the connection of SDOH metrics to HCAHPS scores, patient vulnerability scores based on external data, and the tracking of care utilization for people without housing.

Those on the panel noted their next step is focusing on connecting the dots between their work/ROI and other types of outcomes. One organization talked about tracking utilization for mentally ill patients with housing insecurity as a key area they hoped would decrease costs. Participants feel they are still working on getting data that shows closing social care gaps helps decrease care costs, though they agree tracking the metrics speeds up the SDOH work. Others at the conference, including payers, have also made progress on tracking outcomes to show cost reductions and hopefully increase the adoption of robust SDOH programs.

Summit Attendees

Steering Committee Members

Provider Attendees

Vendor Attendees