To help health systems better understand the impact and cost benefits of their initiatives around social determinants of health, the Commonwealth Fund has created an online calculator to help determine their potential return on investment.

WHY IT MATTERS
As more providers and payers understand the critical importance of social determinants for managing the health and wellness of their highest-need patients, many are implementing programs to address these needs – whether they're related to food access and nutrition, transportation to primary care appointments or any number of other complex social factors.

More and more evidence has emerged in recent years that by addressing these needs – often through partnerships with community-based organizations, ride-share companies, food banks and other local charities – health systems can improve their population health management, reducing emergency department visits and hospital admissions.

As they embark on partnerships with other organizations in the community, however, health systems aren't always clear on how to structure the initiatives, or how to ensure they're delivering the hoped-for results.

Efforts to improve nutrition and housing, offer access to transportation and care management, "all hold promise for better outcomes and lower costs," according to the Commonwealth Foundation. "However, research on the return on investment for addressing health-related social needs is still nascent, and the availability of high-quality studies is limited."

With the aim toward encouraging more "sustainable and effective" SDOH efforts, the group has developed its ROI Calculator, to help healthcare organizations learn more about how their social needs investments "might pay off in terms of cost savings and changes in the amount of health care complex patients use."

Developed by Dr. Victor Tabbush of UCLA and based on work conducted by the SCAN Foundation, the tool is aimed at health systems, payers, medical providers, social service providers and community-based organizations seeking to address SDOH, according to the Commonwealth Foundation.

It allows them to "explore, structure and plan sustainable financial arrangements" to support the delivery of social services to high-need and high-cost patients.

THE LARGER TREND
Smart health systems have known for some time that social determinant data is a key asset when it comes to improving pop health management. That's why leading-edge organizations like Mount Sinai, for instance, are investing in artificial intelligence to help to unlock SDOH data from their electronic health records.

But in the years ahead, partnerships with community organizations will become more prevalent, as Alliance for Better Health CEO (and former chief medical officer and deputy national coordinator at ONC) Dr. Jacob Reider told Healthcare IT News earlier this year.

"We've seen over the past decade that team-based care has been recognized as much more effective, and seen that some practices have even flipped it, and said, 'Hey, the doctor is just the technician. And the care manager is the driver, and they're in charge.' The doctor does what the care manager says they should do, and the doctor is not the quarterback anymore," Reider explained.

"But the key, especially with some of these social determinant things, is that now what we're seeing, which I think is fascinating, is that the team is expanding beyond the practice, beyond the clinic," he said. "So at one facility, we've seen the culture evolve to where the doc and the nurse and maybe there's a care manager there and that's new that they've all started working together. And then they recognize, 'Gosh the food pantry is part of the team. The transportation of poor people, the housing coordinator, the social worker at the county Department of Public Health. These are all members of our team too. Wow.'"

ON THE RECORD
"There is promising evidence that providing supportive housing, both with and without case management, to people who are homeless or at risk of becoming homeless can reduce ED visits, admissions, and inpatient days and result in large decreases in health care costs," said Commonwealth Fund researchers in a blog post. "Similarly, home-delivered, medically tailored meals for those with chronic conditions or at nutritional risk have been found to significantly lower inpatient care utilization, 30-day hospital readmissions, and overall medical costs.

"This calculator is designed to help community-based organizations and their health system partners plan sustainable financial arrangements to fund the delivery of social services to high-need, high-cost patients. HNHC patients, who account for a large share of overall health care spending, often have social needs, clinically complex conditions, cognitive or physical limitations, and/or behavioral health problems. Research shows that complex patients are likely to benefit from a holistic model of care that addresses the social determinants of health such as transportation, housing, and nutrition, in addition to medical needs."