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  • Writer's pictureCare Interface

Strategies for Healthcare Systems to Invest in Social Determinants of Health

A sea change in our understanding of health and its determinants has occurred over the past three decades. A substantial literature now documents how individuals’ genetic and behavioral risks operate in the context of social, political, and environmental conditions that alter access to resources such as healthy food, safety, financial resources, quality education, and gainful employment— all of which shape health outcomes over the life course. Models depicting when and how social determinants of health (SDoH) affect both health and healthcare use have led to calls to address adverse SDoH as a way to reduce health inequities, improve heath, and control healthcare costs. Despite this interest, healthcare leaders are frequently making ad hoc decisions on how they will incorporate this new research into care delivery. Their

decisions are made harder by a lack of information about the costs and benefits of different strategies and of the interventions they entail. A better understanding of the range of options for addressing adverse SDoH may help guide decisions about relevant healthcare system activities Here are the 4 Key Strategies for Healthcare Systems to Invest in Social Determinants of Health:

1 PATIENT CARE–FOCUSED STRATEGIES Social Risk–Informed Care One approach to incorporating the growing awareness of SDH’s influence on health involves more routinely incorporating SDH data into clinical decision-making. Social and economic hardships can pose barriers to accessing high-quality care and adhering to treatment recommendations. Adaptations to traditional healthcare delivery according to information about patients’ social circumstances may help reduce these barriers. But the current process of screening SDoH, populating them in the EHR for physicians, addressing them by navigating to care resources, and finally tracking the closed loop, is fully manual, not just adding an immense amount of cost to the organization, but also limiting such enabling services to only a small fraction of the patients treated.

Care Interface automates all of this process with little to no manual intervention from the care teams at UHB Family Health Services, thereby helping Health systems to screen, identify & address SDoH for more than two thirds of the patients treated at a small fraction of the current cost. The technology also screens patients for potential clinical risks for Behavioral health, Maternal Health, Chronic medical conditions, developmental disorders etc to provide a 360o visibility of each individual’s socio-medical care needs.

2 Social Risk–Targeted Care

A second strategy for incorporating an awareness of SD0H into patient care involves leveraging clinical encounters and Social Determinants to reduce patients’ social and economic barriers to health and health-promoting activities. This is social risk–targeted care. Addressing social risk factors in clinical settings is not novel—it can be traced back through time to innovators like Rudolph Virchow in the 1850s. As modern healthcare systems adopt more social risk–targeted care strategies, they sometimes rely on clinicians to identify and respond to patients’ social adversity (e.g., housing or food insecurity). Increasingly, however, healthcare systems incorporate “link workers” such as care managers, social workers, community health workers, peer navigators, or volunteers to screen patients for unmet social risks and help them navigate relevant services Care Interface Platform addresses these staffing constraints by: Deploying Conversational empathetic bot which converses in mutilple accessible channels like voicecalls, text messages etc. Through the triggered program, the bot interacts in the preferred language of the patient via text message SMS or chat on any phone or device. It interviews patients using evidence driven programs like for SDoH - the PRAPARE tool or bright futures pediatric questionnaire.

The patient interaction is available in multiple languages - English, Spanish, Hindi, Tagalog, Simplified Chinese

  • Options of SDoH Screeners:


  • Health Leads

  • Bright Futures Pediatric Questionnaire Features:

  • Low bandwidth access

  • Conversational Engagement, linguistic and cultural competence

  • In the preferred Channel - text message or online chat

  • Highly secure and encrypted

  • Custom Questions addition to the SDoH screener during implementation process

The Social Needs Identified using our platform’s PRAPARE SDoH Screening:

  1. Socio-Demographic Information (Race & ethnicity, educational attainment, family

  2. income level, immigration status, languages spoken),

  3. Food insecurity

  4. Housing insecurity

  5. Transportation

  6. Interpersonal Violence or Exposure To Violence

  7. Utility Needs

  8. Financial Resource Strain

Optional domains like:

  1. Childcare

  2. Education

  3. Behavioral/ Mental Health

  4. Health Behaviors

  5. Social Isolation & Supports

  6. Employment 3 Advances clinical care by incorporating social and economic risk data into medical diagnosis and treatment decision-making Leverageing clinical encounter and clinical community partnerships to improve patients’ social and economic circumstances. Financial Resource: Harnesses role as a local employer, purchaser, and investor Community Partnerships: Collaborates with non-healthcare organizations in multisector partnerships to combine resources and develop systemwide approaches to improving health 4 COMMUNITY-FOCUSED STRATEGIES

Social risk–targeted and social risk– informed care both are strategies for addressing social adversity in the traditional wheelhouse of medicine: patient care. But healthcare systems operating under value-based payment models or investing in population health outcomes for other reasons may also consider opportunities to intervene on social conditions at the community level as a complementary strategy to patient-level initiatives. These strategies extend the reach of healthcare organizations beyond their own patients to include the health and well-being of people living in a geographical area.

Learn More about how Care Interface helps health systems to address SDoH and improve care outcomes for thier patients here

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