Building a Blueprint for a Social Determinants Program

The current drive for health care transformation has put increasing focus on the socioeconomic risks that impact our health. Underlying social risks such as insecurities around housing, food availability, transportation, employment and domestic safety, to name a few, influence a patient’s health far more than medical factors alone. Physicians can be the tip of the spear in addressing these concerns, but it takes a community to truly correct or mitigate social risks.

One rural region in northern Michigan has been tackling this challenge. Next week, we’ll be publishing a white paper profiling how Northern Physicians Organization worked with its member providers and community agencies to identify at-risk patients and guide them to social services that help meet their non-medical needs.

Data collection, aggregation and exchange play a big role in its social determinants care coordination strategy. You’ll get some insight into the playbook they put together.

What we’re understanding about these types of programs is that even though the concept of social determinants of health has been around for a while, there is no single playbook for how that should be integrated into clinical care. Every community may do it differently because:

• Its patient populations face different challenges.
• Health care organizations of varied sizes have different resources to execute social determinants focused care.
• The stakeholders may differ from community to community.

So there is no single blueprint to build a social determinants program. Likewise, your technical implementation needs to match the profile of your community as well. For example, what is the best way that you are going to coordinate on care among independent provider organizations all running on different health information systems? Who will execute on referrals, and how can automated data exchange make that process more efficient? How can we track followup activities with a patient to measure impact?

So look for an update next week when we profile the NPO case study, and we’ll also look at some toolsets that may be useful to us in the future to support the data exchange for social determinants.