The pandemic has shone a spotlight on longstanding issues with healthcare inequities due to underlying social determinants of health issues, such as living in a food desert, a lack of reliable transportation and unequal access to care.

However, many in health IT contend that healthcare provider organizations can use advanced analytics to surface key insights about their patient populations and take action to ensure all patients have equal access to high-quality care.

Sheila Talton is CEO of Gray Matter Analytics, which offers value-based care healthcare analytics as a service. She is a believer in analytics helping to solve SDOH problems.

We interviewed Talton to get her expert insights into why SDOH issues are so important yet often overlooked, how advanced analytics can be one of the big answers to the SDOH problem, how organizations can surface key SDOH insights about their patient populations, and how executives in charge of analytics can help turn insights into action.

Q. Why are social determinants of health issues, such as living in a food desert, lack of reliable transportation and unequal access to care so important, yet so often overlooked?

A. Let's start with why they're important. Social determinants of health encompass a range of socioeconomic factors that affect individual and population health. These include economic stability, education level, neighborhood and physical environment, access to nutritional food, community and social factors, and access to quality healthcare.

Combined with health behaviors – and here I mean an individual's level of physical activity, as well as use of substances such as tobacco, alcohol and other drugs – social determinants can account for up to 80% of health outcomes. That's quite significant.

It's also fairly obvious. After all, how could a homeless, unemployed person with no health insurance and no easy access to quality care not be at a higher risk for poor health outcomes? So, in that regard it's hard to understand why the impact of social determinants of health has been acknowledged only in the past few years.

But there are two underlying reasons why SDOH historically has not been integrated into healthcare. The first is that under the traditional fee-for-service reimbursement system, providers had no incentives to treat the whole person or practice preventive care.

However, as more providers embrace value-based care – which rewards healthier outcomes and cost savings – they realize the importance of leveraging social determinants to guide care treatment plans and interventions. The second reason SDOH has been overlooked until recently is that providers had no way to access much of this data or analyze it for actionable insights. Fortunately, that's changing.

Q. Why do you say that advanced analytics can be one of the big answers to the SDOH problem?

A. Advanced analytics can help providers looking to change care delivery and approaches around member engagement by enabling them to incorporate information regarding social determinants. For providers using value-based care models, the insights they gain from SDOH data allow them to proactively influence health outcomes.

Advanced analytics meet an urgent need among providers to identify patients at risk upstream and intervene to prevent avoidable care utilization costs.

For example, by applying advanced analytics to SDOH data along with clinical, claims and historical data, providers can identify which patients are at increased risk of behavioral health problems. Clinicians then can intervene with these at-risk patients to offer referrals and treatment options.

An advanced analytics healthcare platform combined with machine-based learning enables healthcare organizations to proactively address physical problems – particularly chronic diseases such as diabetes and heart disease – and behavioral health problems in a way that mitigates future healthcare costs and increases health equity.

Q. How can healthcare provider organizations surface key SDOH insights about their patient populations?

A. Providers must first ask patients about relevant SDOH details, then make sure they collect all the SDOH data that is available to them. This requires connecting with relevant community-based organizations and other third parties to gain access to data, both structured and unstructured, that can be analyzed.

Next, providers should use advanced analytics to identify cohorts of people with common attributes. This enables healthcare organizations to prioritize action based on urgency, severity or cost of the challenges faced by patient groups.

Population data analysis helps providers quickly determine which patients should be targeted for outreach and intervention. Maybe analytics has identified several patients who recently missed their annual wellness visits. Providers then can contact these patients to reschedule appointments or provide other meaningful interventions.

We talked earlier about behavioral health. People struggling with behavioral health conditions such as psychosis and postpartum depression tend to be far higher utilizers than the general population of emergency departments, which are the most expensive form of healthcare. Referring these patients to behavioral health treatment options can better meet their needs while reducing expensive visits to the ED.

Q. How can executives in charge of analytics at provider organizations help turn insights into action that ensures all patients have equal access to high-quality care?

A. That's a great question because it gets to the core issues of turning insights into better care and ensuring equality in healthcare. I firmly believe that without the actionable insights into the whole person that SDOH and advanced analytics enable, and without all people having equal access to quality healthcare, value-based care models will struggle.

One way provider analytics leaders can turn insights into action is by cultivating a collaborative, team-based approach to care in which SDOH and other data is easily shared among and accessed by clinicians and authorized users.

It's hard to have a successful team-based approach without everyone having access to the same data. In addition to improving outcomes, a collaborative, data-driven approach to care will help providers meet and exceed the requirements of value-based contracts.

Getting equal access to high-quality care is a major challenge, but one thing provider organizations can do is work with community-based organizations to build a network of referral services for patients that are identified through advanced analytics as high risk and in need of intervention.

These actions could range from arranging rides to medical appointments to providing referrals to social service agencies for subsidized housing, job training or meal programs. A series of small steps can add up to major changes.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.