Traditionally, HLS companies build their infrastructure around care management services that focus on disease management, medication narratives, and patient education. But as the healthcare industry moves toward value-based care models, providers and payers discovered barriers that interfered with patient outcomes. 

As automated healthcare management systems collect more targeted, meaningful data, healthcare providers realize that addressing a patient’s social needs, or social determinants of health, in addition to providing care, is now the new, more effective, and equitable approach to patient care. 

“It is as if the expressed social need is now becoming recognized as the real barrier to realizing health goals,” says Dr. Jim Walton, president and CEO of Genesis Physicians Group. 

The World Health Organization defines social determinants of health (SDOH) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” 

Whereas traditional care only contributes 10 to 20 percent to the patient’s positive outcome, providing SDOH solutions plays a much bigger role (often 80 to 90 percent) in a patient’s recovery.  

Walton explained that with machine learning technology, data scientists can risk-stratify the population, placing patients with higher burdens of social risk impacting their health access and outcomes at the top, and those with less burden toward the bottom.

And as patient care networks intervene in identified social needs, Walton explained that the changes in both clinical outcomes and social needs can be used in a feedback loop. This loop retrains the machine learning algorithm, helping the model become more precise in determining which social need intervention may have the highest likelihood of producing the greatest positive impact, improving efficiency for the intervening organization.

In other words, the industry is on the pulse of new innovations well-suited to what communities need most. Three organizations are already expanding their services to align with common SDOH solutions that impact patient care: transportation, patient advocacy, and patient care access. Here’s how: 

 

Transportation

Telemedicine is a boon for quick follow-up appointments and check-ups, but most treatment relies on in-person visits. Unfortunately, missed appointments are common among patients for a variety of reasons, including transportation. 

“Nationwide, about 6 million people are missing or delaying medical care because they lack transportation,” said Buck Poropatich, the head of Lyft Healthcare. “Meanwhile, patients who report transportation access problems are about 2.5 times more likely to have a costly emergency department visits.”

This service is particularly strategic for the Medicaid population. Through partnerships with government agencies, including state Medicaid programs in 18 states and the District of Columbia, Lyft Healthcare covers about 45 million of the nation’s nearly 75 million Medicaid enrollees. This is in addition to individual healthcare organizations. 

“The service helped drop no-show rates by 20 percent,” said Sara Heath. “And patient satisfaction scores are sky-high, coming in just nearly at that coveted five stars.”

 

Patient Advocacy

More healthcare delivery systems are moving to interoperability. But while parties exchange data with each other, patients are often overlooked in the process. And that impacts their decisions for care. 

“Since health advocates are the role-appropriate driver of identifying the background, experience and treatment barriers for patients, advocates should be increasingly learning and working on identifying and resolving barriers related to disparities and supporting actions to move us towards health equity in the healthcare system,” explained Robin Shapiro. 

Shapiro explained that health advocates have unique skills to assist both the provider and the patient by making sure the provider sees the patient as an individual, considers choices from the patient’s perspective, and meets with the patient before the patient’s appointment to discuss areas of concern, trauma, discomfort, etc. “By working alongside the patient, advocates can identify and reflect back what is happening during a provider visit or interaction,” says Shapiro. “This may be helpful in having a second set of eyes and ears in the situation.”

 

Community Access 

A strategy that has been quite successful is meeting where the patient is. One company that has done a tremendous job of doing that is CVS Health. By opening up a series of small clinics, CVS literally meets where the patient is. They have access to patient information based on what type of medicine they’re prescribing to members of a community, and they know the issues and barriers people face. This access to data positions CVS to move toward value-based and preventative care. 

What’s more meaningful is not only meeting these patients where they are but collecting the data from patients where they live. Through existing pipelines and interoperability, parties can exchange data that define population health, not necessarily about singular patients but they can gain a better understanding of population health geographically. With this information, payers can make more informed decisions and establish risk stratification to better serve communities. 

To make an impact on community health, healthcare providers need to understand what the neighborhood needs. That’s why data is essential. Whether those solutions involve providing transportation, support, proximity to care, or other social determinants of health, partnering with organizations who offer solutions to common patient barriers helps healthcare expand its reach, armed with reliable data to ensure resources are available in the communities that need them the most.