Connecting Patient Needs with Local Resources: How Social Determinants of Health Enhance Healthcare Outcomes

In an old fable, several blind men approach an elephant. They each touch different parts of the mighty beast and describe their limited perceptions. One grasps the trunk and perceives a snake; another feels the ear and senses a fan. They all make their unique contributions, but none of them grasp the full reality of the elephant. 

This parable clearly illustrates the fragmented nature of the healthcare system, which often focuses on isolated parts of a patient’s health without considering the holistic picture. To truly advance public health and promote well-being, it is imperative that we embrace the importance of social determinants of health (SDOH), which are the factors that shape our lives and contribute significantly to our overall health outcomes.

In the realm of healthcare, our attention has historically fixated on the immediate and tangible aspects of illness and treatment—such as symptoms, medications, and surgeries. These components, analogous to the blind men’s perception of the elephant’s parts, are absolutely essential. However, they represent only a fragment of the intricate web of factors influencing an individual’s health.

Just as the blind men’s perceptions were limited by their focus on isolated parts of the elephant, a healthcare system that fixates solely on symptoms and treatments neglects the broader determinants that shape an individual’s health. Factors such as economic status, education, housing, employment, access to nutritious food, and even the surrounding community all play pivotal roles in health outcomes. Research has even shown that a patient’s SDOH contributes to 30% to 55% of their overall health outcomes. ¹

To place added emphasis on the importance of identifying the SDOH in healthcare, CMS will require hospitals to screen for the following in all admitted inpatients in 2024: ²

• Food Insecurity
• Interpersonal Safety
• Housing Insecurity
• Transportation Insecurity
• Utilities (electricity, water, A/C, phone, etc.)

Furthermore, The Joint Commission has added to the regulations by stating all of the following types of facilities must all also screen their patients for SDoH:

• All critical access hospitals and hospitals
• Ambulatory health care organizations providing primary care within the “Medical Centers” service in the ambulatory health care program (the requirements are not applicable to organizations providing episodic care, dental services, or surgical services)
• Behavioral health care and human services organizations providing “Addictions Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays,” “Mental Health Services,” and “Primary Physical Health Care” services

They will also need to ask questions about:

• Access to transportation
• Difficulty paying for prescriptions or medical bills
• Education and literacy
• Food insecurity
• Housing insecurity

While beginning to track and record the SDOH of patients is important, even more so is the ability to do something to address these needs. Some healthcare organizations may balk at the challenge of stepping in to influence a patient’s life outside of the hospital walls, but others will begin to see the whole elephant, and recognize this as an opportunity to bring long-lasting improvements to not only their patients’ health, but the health of their communities as well.

How can The Community Initiative and Wixcorp empower hospitals to successfully address a patient’s Social Determinants of Health?

Wixcorp is excited to partner with The Community Initiative (TCI) to provide hospitals with community resources that can help improve the social determinants of health for patients across the country. TCI leverages real-time interfaces with a dedicated team of analysts to maintain a comprehensive and accurate database of resources that can be targeted and personalized to meet individual patient needs.

Through this partnership, hospitals can now not only collect and report on patient SDoH, but can also automatically correlate individual patient needs with local community assets that can be beneficial.

Most health systems have processes in place to collect information from their patients regarding their health-related social needs and notify Social Workers and Case Management departments. Unfortunately, those processes are often subject to the pitfalls of manual data entry and can be very time-consuming for hospital staff.

To help improve SDOH tracking and trending, a new class of codes was added to the ICD-10 database in 2015. More recently, CMS released its recommendations on how the industry can leverage this new code set to help healthcare providers better identify the SDOH needs and outcomes of their patients. You can view CMS’s recommendations here.

To help connect patient needs with resources, The Community Initiative has built out a list of 500,000+ local and national resources that match SDoH needs. When connected with Wixcorp’s patient engagement engine, Redde, institutions can have access to intuitive texting and digital forms tools to help patients quickly and easily complete their own screening questions and be matched to personalized community resources from TCI. Patient responses are recorded with the appropriate Z-codes for easy reporting and billing.

Hospitals will also have access to real-time data to show the impact of the efforts you are putting into the community. For example, if a hospital donates a significant amount of resources to a local food bank, they can then track the data over time to track the impact of that donation on the food insecurity levels of the target patient population.

This new partnership between TCI and Wixcorp will allow hospitals to streamline patient access, track population health specifically, and incorporate community resources with discharge processes like never before. These technologically empowered solutions will not only meet the new SDOW compliance standards from CMS, but will, more importantly, quickly connect patients with personalized resources that will better support them on their road to better health.

Visit this site to learn more about how to successfully comply with this new CMS standard, and improve the SDOH metrics of your patients and community at the same time.

References: 

1. World Health Organization – Social Determinants of Health
2. HIMSS – Addressing Social Determinants of Health (SDOH) in Healthcare Part 2