1. Using data to identify those at risk. Before health care organizations can start to address SDOH, they must first identify which of their patients are having trouble. Hospitals, physician practices, and other providers collect myriad data about patients, as do their health partners, including payers and pharmacies. Within this data, there are some key indicators that could point to SDOH concerns. For example, if patients are not filling or refilling their prescriptions regularly, there may be medication adherence issues fueled by a lack of transportation or financial barriers. Similarly, frequent appointment cancellations or a lack of scheduled follow-up visits may indicate a problem. With advancing data analytics capabilities, organizations have the opportunity to use predictive algorithms to calculate the likelihood that someone is facing SDOH challenges and could be a good candidate for intervention.
Although algorithms exist today, the opportunity for advancement in this area is significant. Current options rely mostly on provider and payer data, but to be more effective and accurate, the algorithms will need to incorporate nontraditional data as well, such as that from public databases, community-based organizations, wearables, and more.
2. Supplementing data-driven identification with point-of-care identification. Predictive analytics is not the only identification strategy that works. There are less technology-dependent options that can still make a difference. For example, we collaborated with a Texas-based provider organization to create a process whereby physicians can refer patients who may need assistance to a team of Health Advocates. This team, which includes social workers and nurses, contacts patients to discuss their needs and then connects them to the right resources, making a clear difference in the community.
3. Connect with patients in meaningful ways. Once an organization has an idea of who may be at risk, it can start reaching out to patients to gather more details about what help they need. Not everyone has the same SDOH concerns, so solutions must be individualized to meet unique patient requirements. Having a supportive framework in place that includes care coordinators, social workers, dieticians, and nurses can enable an efficient, consistent, and compassionate outreach process. By using a questionnaire that team members can use to assess a patient’s current circumstances, organizations can ensure they are capturing the relevant information and creating a true picture of the patient’s situation. One such tool is the
PRAPARE assessment. PRAPARE stands for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. It is specifically designed to help providers collect actionable SDOH data.
