How to Track Social Determinants of Health and Share the Data

Why The MACPAC Beneficiaries Decision Matters To You

While human services and healthcare organizations alike are eager to form partnerships to share data to jointly address the social determinants of health, obstacles quickly arise that inhibit the ability of organizations to collaborate across disciplines. Some of these challenges are technological, some are legal, some are financial, while others are political. Despite the challenges, some organizations are finding ways to circumvent the challenges in order to achieve their goal of providing improved healthcare experiences by helping healthcare and human services organizations jointly address the social determinants of health. Let’s take a look at a few examples:

Bay Area Regional Help Desk Consortium

In San Francisco, the Bay Area Regional Help Desk Consortium brought together hospitals and social services organizations to tackle the challenges of low-income patients. The consortium includes three health systems, four universities, a public health department, and social service providers in the San Francisco Bay area.

The consortium chose a help desk model, with each participating hospital setting up a volunteer-staffed help desk for patient intake. As information is collected on the social determinants of health, volunteers contact social services and legal aid referral services to meet patient needs. Information is coordinated and shared across the system to the benefit of all involved. Hospital-based helpdesk volunteers even place follow-up calls to verify that action has been taken on addressing identified social service needs.

Data sharing is facilitated by a centralized intake point, with clear referral channels correlated to patient needs. It is interesting to note that the data collection to identify social determinants of health happens outside of the hospital EHR system because they found it too complicated to modify the EHR for evaluation activities. A dedicated care coordination system is often more appropriate for this purpose.

Health Leads

The Health Leads program, based in Boston, Massachusetts, allows medical providers to prescribe basic human needs resources, like food or heat, just as they prescribe medication or equipment. Physicians refer patients to Health Leads just as they refer to other specialty providers. When a patient arrives at Health Leads their prescription is filled using organization resources and referrals to other community services partners.

Because the program necessitates sharing health information data among healthcare providers and community services organizations, Health Leads maintains HIPAA business associate agreements with all partners to allow for appropriate data exchange.

Data sharing is done by a combination of paper referral forms and information entered by volunteers into a case management system.

Camden Coalition of Healthcare Providers

In Camden, NJ, a citywide coalition of hospitals, community representatives, and primary care, behavioral health, social service, and housing providers has formed to tackle the challenge of frequent utilizers of the city’s emergency departments and hospitals. The goal is to reach out to these patients and connect them with lower cost community resources that will address the social determinants of health. Patients are referred to primary care services, specialty medical care, housing, government benefits, and other resources.

The program uses a housing first approach to place patients with complex health needs into available housing, which helps reduce hospitalizations and brings down overall cost of care.

Data collection is performed by a nurse or social worker who collects both medical information and social information from patients. The social determinants of health information is tracked in an online database and shared among community participants using a health information exchange.

Creating Partnerships

When looking to create a data sharing partnership, five key steps should be followed:

  1. Identify the partners — In the examples above, each group formed a defined partnership of healthcare providers, social services organizations, and often a public health department or other government entity. It’s important to keep in mind that community pain points are shared by all organizations who co-exist within that community.
  2. Determine scope — Some programs address multiple facets of the social determinants of health. Others focus on one or two key areas — housing or behavioral health, for example. It’s important for all partners to agree on the scope up front.
  3. Establish communication and data sharing protocol – Partners should clearly understand who will be performing data intake, what systems will be used, and how that information will be shared with other partners. A care coordination system greatly simplifies the task of collecting and sharing information across multiple partners.
  4. Promote internally and externally within the community — Once the partnership is established, promote the coalition’s capabilities to other healthcare providers and social services organizations. They may be looking for the resources now available.
  5. Monitor and improve — Monitoring the success of joint programs to address the social determinants of health is essential to growing program offerings, obtaining additional funding, and improving the patient experience. A care coordination system should provide powerful reporting tools that allow close monitoring across multiple programs, providers, and specialties.

Though not always easy, creating partnerships to address the social determinants of health allows organizations and providers from a variety of fields to bring together their collective expertise as they work towards achieving the common goal of all healthcare and human services providers; namely, to achieve the best possible long-term outcome for each and every individual.

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