The Xs and Os of SDOH, FTW

Strategy of Leading Social Determinants of Health Programs


Pardon the alphabet soup — A cold snap has hit us hard here in DC, along with the rest of the East coast. We’ve been using the weather to hunker down with hot soup and coffee, reading up on strategies for how communities are improving their approach to managing the social determinants of health (SDOH). An excellent report by the Center for Health Care Strategies breaks down how six such communities around the country have done just that as part of multi-site program funded by the Robert Wood Johnson Foundation.

What follows is a summary analysis of the report, and some added color commentary on how the worlds of public health, healthcare, and health IT are rapidly converging as we move further into 2018.

Four key steps of implementing an SDOH Program

Boiling something down to key steps doesn’t make the work easier, but it can help promote a high level understanding of complex issues. When it comes to picking and implementing tools for SDOH, it takes:

  1. Selection — Choosing and customizing a needs assessment tool
  2. Integration — Incorporating the tool into an organization’s process(es)
  3. Workflow — Adjusting and defining roles and responsibilities around the new tool
  4. Referrals — Identifying social support, referring accordingly, and following up

Selection: A Hodgepodge of Assessments in Need of Standardization

To say US healthcare has historically paid little attention to SDOH is old news, but not fake news: We’ve now got so many standardized clinical measures for blood sugar and cancer and behavioral health and asthma that doctors are complaining; meanwhile the measurement of what’s driving those conditions in patients in the first place has been an ad-hoc chore, un-mandated, unstandardized, and mostly unpaid.

The result? Numerous screening tools have piled up over the years, with many overlap and gaps between them. Academic groups, non-profits, and commercial vendors have all released their own assessment tools over the last decade. The Institute of Medicine (IOM) proposed standardizing a set of wide-ranging domains in which to assess patients’ needs, which was well received but whose adoption remains voluntary and thus uneven. More recently, the Centers for Medicare and Medicaid Services (CMS) released a much-simplified screening tool for the Accountable Health Communities (AHC) program.

Image from Center for Health Care Strategies

Once the organization picks their assessment tool, there’s the matter of customizing it for “provider comfort level and preference” across different clinical sites and often, individuals. Some communities add in their own questions (e.g. connection to a religious community), others remove or limit questions they feel might violate HIPAA or other consent laws.

Remember: If someone, somewhere wasn’t worried about violating HIPAA, it wouldn’t be innovative.

Integration: Plug and Play (and maybe Pay)

Once organizations know the questions they want to ask their patients, they’ve got to figure out how to keep track of the answers to those questions. According to the report, this usually means electronic integration of the entire survey into a care coordination tool; either directly into the electronic health record (EHR) system, or into third party care coordination software, or even through bolt-on clinical tools.

One neat example shared how Thedacare, a health system in Wisconsin, plugged the assessment tool into a mobile read/write EHR interface for their paramedics to use, resulting in an average reduction of 15 minutes(!) on a home visit. That adds up to real time and real money, folks.

However, as a caveat, the six sites in the report are akin to honors students, while the vast majority of hospitals are further behind, using paper process and ad-hoc data capture as described recently by Deloitte. The writing is on the wall for this to change in the next few years however, for two reasons: First, CMS has turned an eye towards social needs assessments as part of their AHC program, and more broadly, value-based care models are demanding more holistic approaches to population health management, which will all require the ability to capture needs assessments and more electronically.

Second, with large EHR vendors investing heavily in care coordination and announcing a shift from EHR to “CHR”, SDOH will soon become a more prominent upsell to their captive hospital customers who, as described in the Deloitte survey, seem unlikely to teach themselves any new tricks anytime soon. As a general cautionary note against inevitable health IT hype: This is going to take time, and adding technology into the mix will only help if it doesn’t lead hospitals to think they needn’t do anything else.

Workflow: When and Who

As the great healthcare innovator Inigo Montoya once said of workflow, “You keep using that word. I do not think it means what you think it means.” Health IT discussions about workflow inevitably become too complex for any layperson to understand, so the simple description of SDOH workflow considerations boils down to When and Who.

At the point that organizations have selected their assessment questions and figured out how to capture the data automatically, the next step is determining when patients get screened to assess social determinants, and who is responsible for doing so. As the report smartly points out, this has a two-tiered benefit: Immediately, it ensures appropriate data capture and follow-up so the patient gets what they need; At the meta-level it enables a standardized data set that’s useful for population health analytics on trends, gaps, performance, and so on.

The “who” can be a trickier question. Inside an organization, a nurse, case manager or other clinical care manager type is often the one who onboards a patient and screens them for any social or environmental needs (e.g. during a hospitalization or annual physical.) Yet outside those walls, social workers, community health workers, visiting nurses, or others serve as more frequent touchpoints for post-discharge care. It’s not difficult to imagine that a visit to a patient’s home might offer more insight into their social needs than surveying them when they’re coming off anesthesia in a hospital bed.

Sometimes, as described above, paramedics or first responders are often the first touchpoint, meaning they’ve got an opportunity to do the initial onboarding. These ‘beyond the hospital walls’ scenarios speak to two things: First, to the importance of usability and well-designed software for end-users who are on their feet, busy, and perhaps less facile with mobile software. And secondly, the more general challenge that hospital-centric health systems face in figuring out how to impact health outcomes in places where they don’t really spend much time at all.

Referrals: Finding support and closing the loop

This final step is where much of the attention and interest in SDOH seems to be heading these days. Once an organization has figured out what a certain patient needs, be it legal support, enrolling in a SNAP program, or transportation, matching them with an appropriate source of help comes down to three steps:

  1. Identifying the right resource for the patient
  2. Referring the patient to the appropriate community-based organization (CBO)
  3. Following up to make sure the right help was provided. This is where most healthcare organizations need help, whether or not they are willing (or able) to acknowledge it

Identifying the right resource means knowing what resources exist in the community. Historically, this has been a paper-heavy process aided by social workers, local non-profits and other organizations, but more recently the community resource directory has gone digital, thanks to variety of organizations who have stepped up to the plate. 211, a national service supported by United Way, maintains lists of social services and organizations that serves as a first pass of who’s doing what in a given community. Some organizations may use this as a starting point for building their own resource directory, alone or in conjunction with local partners.

The referral and especially the follow-up process however, require a more sophisticated offering than just a social services search engine. As electronic data capture and standardization have trickled into hospital systems over the last decade, organizations like Health Leads and Aunt Bertha created their own versions of these directories, soon joined by a growing list of companies like OneDegree, Healthify and Purple Binder (the latter two just merged), and more recently, UniteUs, NowPow, and many more. (Note: This class of vendors is the subject of an upcoming research report we’re putting together, please contact us to learn more or get involved.)

In Closing: Real World Barriers Remain

While the six examples outlined in the report may represent advanced organizations, that doesn’t discount the difficulty of their innovation journey on the SDOH front. Moreover, even they had to start somewhere — in some cases, with paper assessment tools and manual referrals. Their lessons for success:

  • Social needs are a delicate subject: Asking someone about their drinking, or drug use, or if they’re able to feed their children, can lead to a quick erosion of trust and communication. While it’s easier not to talk about these issues, which is why healthcare historically hasn’t talked about them, it’s a lot more expensive and ineffective to leave them under the rug.
  • Referral Networks are critical: More than just compiling a list, ideally organizations will be able to skew their supply towards their patient population’s popular demands, and develop responsive follow-up processes to ensure help is being delivered where and when it’s needed.
  • Don’t Build, Borrow: With several proven SDOH assessments available, some of which are already EHR-compatible, CHCS advises organizations against reinventing the wheel by developing homegrown screening tools.
  • Break down Silos: Multi-sector partnerships between health systems and local CBOs are critical, but they’re not easy, exacerbated by a lack of common culture and mission, as well as vast discrepancies in technology, training, and resources ( Many more insights in a recent Health Affairs piece)

We look forward to covering more of these important issues as the evidence grows around social determinants of health. It may be a nifty hashtag, but let’s not lose sight of the importance of this work: It’s all about figuring out how we can lead people to the help they need, so they can get back on their feet, take better care of their families, and live healthier lives (which can also wind up saving everyone money.)

A hearty Thank You to Caitlin Thomas-Henkel and Meryl Schulman, authors of the original report at the Center for Health Care Strategies.

Are you interested in SDOH-related innovation? Let us know! Share any thoughts, ideas, examples, or other resources with us in the comments, or get at us on Twitter! @patchwiselabs @onboardhealth


Naveen Rao is Managing Partner of Patchwise Labs.