Provider with patients

What Health Centers Need To Advance SDOH Programs

Social determinants of health (SDOH) are too often regarded as factors separate from clinical care. As the healthcare ecosystem becomes more collaborative, however, stakeholders will act on SDOH data as an inherent part of clinical decision-making.

It’s likely to take years of sustained investment and creativity from across the entire care continuum before SDOH programs become part and parcel of routine care. But it’s the right moment in time to make that commitment. Financial incentives are contributing to this change, and providers have access to more sophisticated technology and revenue cycle management (RCM) tools than ever before to support their journey in systematically addressing SDOH.

Health Centers Have Insight on SDOH

Health centers engage predominantly underserved populations that tend to experience barriers to care and SDOH more often. In fact, 91 percent of the people they serve are considered low-income, and health center patients are disproportionately uninsured or publicly insured, according to the National Association of Community Health Centers.

By addressing SDOH, health centers advance their mission to care for their communities. This truly comprehensive care also delivers better outcomes, leading to improved reimbursement, especially for care providers that are expanding into risk-based arrangements.

Collecting Data on SDOH

Without complete data about each patient’s unique socioeconomic challenges, health centers are blind to their needs. The historical view of SDOH has typically been distinct from clinical care, but that’s beginning to change.

Many EHRs have evolved to include native capabilities to collect and integrate non-clinical data into the care process. From ICD-10’s Z-codes and AHRQ’s SDOH database to the HL7 International Gravity Project, the technology infrastructure has evolved to capture the incidence of common social determinants.

Health centers must create data-collection plans as well as data-use plans that form the backbone of their SDOH efforts. Laying this groundwork in advance will help them begin new programs with the appropriate inputs that will inform referrals, care plans, and collaborative action.

Creating Workflows to Address SDOH

When it comes to addressing SDOH, “actionability” doesn’t lie in the hands of a single provider. Individuals with socioeconomic challenges usually benefit from a coordinated care team that includes clinicians, social workers, pharmacists, behavioral health providers, and community-based organizations like food banks or transportation services.

Each of these care team members needs to know what has been done to assist the individual and what remains to accomplish. Yet many health centers are unable to make direct referrals to external services, either because they currently lack the financial incentives to support such work or they simply don’t know how to engage with organizations in their area.

Consider enlisting business transformation experts to assist in technology selection, clinical workflow solutions, and partnership development before creating a strategy to address SDOH. With a solid foundation in place, health centers can build out the logistics for new programs that are designed to drive financial and clinical results.

Prepare For Value-Based Payment

Increasingly, payment mechanisms have aligned financial incentives across the care continuum to make the effort to address SDOH sustainable for healthcare organizations. Addressing social and lifestyle needs is gradually becoming a natural part of delivering whole-person, value-based care, and payers are eager to contract with providers that can demonstrate a positive impact on outcomes.

Transitioning to value-based payment arrangements offer health centers the latitude to address SDOH. By allocating resources under a capitated model, health centers can provide any of an array of helpful services for their patients that lead to optimal outcomes, rather than being limited to delivering only specified services that result in payment — as is the case with rigid fee-for-service models.

Actions to prepare for value-based models that lend themselves to programs to address SDOH will vary for each provider’s unique situation. However, some readiness steps might include:

  1. Assessing your current operations, including technology, revenue cycle management, and partnerships.
  2. Exploring opportunities for value-based care arrangements in your market.
  3. Calculating the financial proposition of delivering value-based care for your populations.
  4. Transforming your business and clinical processes to support value-based care.
  5. Designing and implementing specific programs to identify and address SDOH.

To fulfill the mission to care for underserved and vulnerable communities, health centers can’t afford to forgo the initial groundwork needed to address SDOH. Reach out to the Monarch Health Solutions team to create a unique, sustainable path forward that allows you to solve for social determinants that cause barriers for your populations.

Contact our team for an initial consultation.