In our last column, we talked about social determinants of health, or SDOH, and their influence on patients’ health status. Factors like neighborhood, race, English language fluency, income, access to transportation, education level and the presence of family, friends and other social supports can all play a role in whether patients can sustain a healthy lifestyle and comply with care plans.

Some studies show that up to half of a patient’s health status is determined by SDOH. Providers who were paid on a fee-for-service basis may have had fewer reasons to address SDOH factors — at least from a financial point of view — but value-based reimbursement has brought these factors into prominence.

As providers of information technology, we are inspired by the number of ways that IT can help providers rise to this new challenge of incorporating SDOH into the maintenance and improvement of their patients’ health. Getting the right systems in place will be a challenge — to technology, to workflow and to overall IT strategic planning. The effort will require investments in areas that health IT has historically not touched: integrating SDOH information with the electronic health record and population health management systems; making referrals to social service resources; and perhaps even extending the reach of health system IT into community agencies.

Our previous column discussed the role of data and analytics in determining which patients are at risk due to SDOH factors. Here we will outline some tasks that providers must accomplish in order to get essential information to clinicians, care managers, social workers and community organizations so that all parties can work together most effectively to help their patients.

Adding SDOH to the workflow

We assume that a provider has acquired the data and analytics capabilities that yield patient-level SDOH information (a big assumption, we know). How do we add it to the workflow in a way that will help clinicians and the care team ask good questions and give the best advice and referrals at the moment those things are most needed? While we are in the early stages of applying SDOH to EHR and population health management applications, it is clear that the IT to-do list includes:

  • Providing visibility to a patient’s SDOH information to caregivers at the point of care: Not every patient will have problematic SDOH. Some may have only one troublesome situation, and others may have multiple social factors standing between them and optimal health. The SDOH tool should flag the determinants that need attention. This information will be needed by multiple members of the care team: physicians, nurses, care managers, pharmacists and front office staff.
  • Allowing providers to develop a social care plan that's integrated with the clinical care plan: The care plan should expand to include the social concerns that impact health outcomes and ways to address those concerns. For example, a care plan for a congestive heart failure patient may assume access to a bathroom scale, a telephone and transportation to appointments. A homeless CHF patient may have none of those things. How can the plan be adapted successfully, and what nonclinical resources are needed? A care plan for a patient with diabetes who’s at risk of domestic violence may involve helping her find a safe shelter. If her care team has been reaching her at her home for monitoring or appointment reminders, they need to find a new way to keep in touch.
  • Assigning tasks: The more complicated the plan, the more challenging it will be to ensure that all the tasks get done. For each task in the plan, there must be a mechanism to assign it to the appropriate care team member. Some SDOH factors, such as those above, may be handled by members of the care team other than the physician. Each member should be able to see the task lists of other members and assign tasks as necessary.
  • Automatically linking to resources to address the needs flagged in the social plan: This functionality requires both an up-to-date database of resources (a challenge we discuss in more detail below) and a mechanism for integrating the database into the social plan functionality. This functionality integrates resource options into the clinician's workflow and notes the health system’s preferred social service providers and any preferences or limitations they may have. The functionality must also note any relevant patient preferences, such as location, language interpretation services and compatible faith orientation. Finally, the system must close the loop by enabling back-and-forth communication between the medical provider and the social service provider.
  • Serving up educational materials linked to the flagged social concerns: Local community organizations may have appropriate materials or be able to recommend reliable sources.
  • Supporting patient interaction with social services: Patients should be provided resources that help them find and use social services. These resources could include virtual and in-person communities of individuals with similar challenges, a means to communicate directly with social services organizations and information about any requirements that must be met (for example, proof of income or enrollment in related programs) in order to utilize services.

Also worth exploring are ways to help patients use mobile phone apps to close their own SDOH-related loops. A recent study showed 64 percent of adults with household incomes under $30,000 have a smartphone, though they may lack access to a computer, according to the Pew Research Center. Aunt Bertha, one of the resource providers mentioned below, is helping New York City link its smartphone users to social services via free public Wi-Fi kiosks. Providers could include access to social service resources as part of their existing mobile apps or encourage patients to use freestanding apps already available from some of the companies and organizations mentioned below.

All of these IT capabilities rest on a foundation of partnerships between health care providers and social services organizations.

Establishing and managing social services partnerships

One of the more challenging aspects of wrapping SDOH into a care plan is figuring out who can best help solve a given social problem. Some providers with large Medicaid and uninsured populations (for example, Montefiore Health System in New York) have long addressed SDOH in their communities and have developed some of their own resources, but most will have to reach out to community organizations and social service agencies, whose budgets and fortunes may rise and fall unpredictably and whose staffs are often in flux.

The IT department may not be given the responsibility for developing these partnerships, but it might be asked to devise methods of maintaining an up-to-date database and will almost certainly be asked to integrate referral tools into the workflow. A number of efforts, both commercial and nonprofit, have sprung up to fill these needs. They vary in their specific services and their completeness, and keeping current is always a challenge. No single source is likely to fulfill all of a given provider’s requirements. But we suggest checking out these to get a running start:

  • 211: A service of the United Way that rounds up links for all “211” health and human services referral services in the U.S. and Canada.
  • Aunt Bertha: A for-profit organization that claims links to hundreds of programs serving every U.S. ZIP code. Basic use is free, with advanced collaboration features available at various price points.
  • Healthify: A for-profit offering database, EHR integration, assessment tool and analytics.
  • Health Leads: A nonprofit offering tools, training and resources for integrating SDOH into accountable care.
  • NowPow: A for-profit offering curated resource lists and patient engagement tools.
  • TavHealth: A for-profit offering database, collaboration tools, analytics and community resources management services.

Integrating IT in the community

As providers implement IT support of SDOH, they will need to interact with the IT capabilities of a potentially wide range of social services organizations. These organizations will vary wildly in their level of IT experience, expertise, existing systems and budget resources.

At a minimum, the provider’s care team and the community agencies should be able to send and receive secure messages, and those messages should integrate into the patient’s EHR and population health management systems so that everyone can keep track of the social care plan in much the same way as specialists close the loop with primary care providers. Social service agencies, community health workers or others may need at least partial access to EHR and population health management information in order to track the patient’s progress or respond to flagged needs. In cases where collaborating agencies have appropriate IT, providers may be able to use communication standards like SMART on FHIR to provide useful integration.

Still uncharted territory, but we think highly worth exploring in some situations, is extending the capabilities of health system IT into the community organizations that are most involved in addressing your patients’ SDOH issues. Some providers have been through a version of this process when extending EHR access to physician practices in their communities. In conjunction with that effort, the U.S. Department of Health & Human Services extended the “safe harbor” rule for EHR donations until 2021. While the two situations aren’t exactly parallel and providers will want to consult their attorneys on legal and regulatory aspects, many providers are uniquely positioned to offer some social service providers a badly needed IT boost that can also solidify community partnerships.

Innovating for social health

Addressing a patient’s SDOH factors will enable us to take significant leaps forward in improving the health and health care of patients and communities. The evolving integration of medical care and social care is already leading to impressive innovations by care providers. These innovations will be able to make significant advances as we extend the IT capabilities to deliver robust and full-function SDOH support. Here are a few current innovations that we find extremely promising:

  • New York’s Mount Sinai Health System recently launched a partnership with several legal aid services to address legal issues that can be barriers to good health and optimal care. The attorneys will help with trust and estate planning (for terminally ill patients), changing names and stated gender on legal documents (for transgender patients), and legal services for at-risk children and youth in their interactions with the educational system and the criminal justice system.
  • Geisinger Health System offers “Fresh Food Pharmacy,” a program that helps food insecure diabetic patients get free groceries and meal plans that help keep their disease under control by giving them food “prescriptions,” along with monitoring and coaching.
  • Carolinas Healthcare and Novant Health, normally competitors in North Carolina, are working together using data from Quality of Life Explorer, an SDOH mapping application developed through a collaboration of several organizations and public agencies. Among other projects, they will coordinate on where to put new primary care clinics, identify food deserts and address high rates of diabetes in certain neighborhoods of the communities they both serve.

With the amount of energy and imagination in our industry, we know that these few examples are just a taste of what is to come. We have not yet even begun to see the full range of ways that addressing SDOH can improve community health.

Editor’s note: The American Hospital Association’s Task Force on Ensuring Access in Vulnerable Communities recommends addressing SDOH for preserving access to health care services. A report from the task force, including case examples and best practices, is available here.

John Glaser, Ph.D., is senior vice president of population health with Cerner in Kansas City, Mo. He is a regular contributor to H&HN’s web site. Tanuj K. Gupta, M.D., MBA, is senior director and physician executive of population health with Cerner.