Who Are the Key Players in Social Determinants of Health Strategy?

January 02, 2020 - The healthcare industry has come to a consensus that the social determinants of health and population health are essential considerations for delivering on value-based care. But it takes a village, as the adage says, and organizations need to anticipate a number of stakeholders for making these programs a reality.

SDOH programs are inherently multi-stakeholder — they require the medical provider who will identify high-risk patients, fund sources, care coordinators or caseworkers, and the community-based partners that will help carry out interventions. Each of these stakeholders needs to be working in the same direction in order for programs to be successful.

Ultimately, this direction needs to come from the top of a healthcare organization, according to Steve Miff, CEO of the Parkland Center for Clinical Innovation (PCCI). These are key stakeholders who have a lot of control in organization decision-making, including the power of the purse.

Getting board members and other executive-level leaders on board with SDOH programming may not be the mountain many population health experts believe they must climb. In fact, Miff says many board members and executive leaders already have the social determinants of health top of mind.

“Boards and leadership teams have been somewhat thinking about SDOH particularly since they've consistently and periodically had to complete a community health needs assessment,” Miff said in an interview with PatientEngagmentHIT.com.

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“However, the needs assessments in most organizations — not all — generally have been something that's been a bit more of a check-the-box versus really driving an organization plus strategy. But with an increased focus on and recognition that social determinants of health and the elements that play out in the community, leadership is beginning to use these factors to develop organizational strategy.”

And as a fundamental part of that duty, board members are considering where to allocate financial resources to fund SDOH programming.

That’s where a hospital’s population health experts and other leadership step in. These individuals need to make the financial case for both the health system or plan and the community-based organizations that will operate SDOH programs. Demonstrating a potential return on investment and showing that certain interventions will be effective is key, Miff stated.

Ultimately, making this financial case will help create a governance structure for an SDOH intervention.

“By determining those upfront, you know now how you are going to measure the program’s success, you know how much it's going to cost, and then you start to be able to map the initial financials,” Miff explained. “Then you can determine the plan for subsequent years and where that funding is going to come from.”

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Insofar as specific financing is concerned, Miff recommended healthcare organizations create a diverse funding stream.

“It’s hard to expect one entity to support the whole program,” he said. Although many healthcare organizations are beginning to fund SDOH programs because they can see the ROI, Miff made the case for other funding streams to support a more sustainable ecosystem. Specifically, grant programs and other reimbursement options will help diversify these programs and make them more secure.

The board plays a role in more than just the financials, Miff reminded. Hospital and health system board members tend to be well-connected individuals who play a large role in the community. In other words, board members can help hospitals make community health partnerships and maintain them.

“To roll out these community-based community connections with any of these programs, it requires participation from not only the local municipality but also non-healthcare entities in the community,” he explained. “And the boards can be that liaison to those leadership teams and to those community-based organizations.”

And to that end, medical organizations can begin to approach these SDOH programs as an equal partner, not necessarily as the leader. Although there are certain cases where a hospital may spearhead an SDOH program, these interventions are most meaningful when all stakeholders have an equal place at the table.

“Healthcare organizations need to approach this as being an equal partner,” Miff said. “In some cases, they need to feel comfortable not leading an initiative but being actively engaged in support. So they don't necessarily need to lead a connected community-based initiative, but they at the very least need to be very actively involved.”

This means hospitals, health systems, or payers might be playing the role of benefactor and propping up smaller organizations that can have a more impactful footprint on SDOH work.

“There should be a mix of smaller independent organizations as well as ideally some umbrella organizations,” Miff stated. “They represent a consortium of food pantries or homeless shelters or other community-based organizations. By having larger consortium-based organizations at the table, it somewhat levels off that playing field.”

And in doing this, healthcare organizations and community partners alike can ensure SDOH programming works for everyone involved. Currently, SDOH programming looks at issues largely from the healthcare perspective, whether it be to target utilization, outcomes, or other key factors. Providers screen individuals and refer them to support out in the community, which Miff said is a good first step.

“But there need to be dollars allocated for those community-based organizations to then be able to provide additional services and additional support to those individuals who are now increasingly being referred to them,” he outlined. “Don't just assume that, ‘hey, we're going to just send them patients and they'll figure out how to do it.’”

For example, many organizations currently have or are acquiring a directory of community-based organizations integrated within their EHRs. This allows clinicians to refer patients to community-based resources.

“That's a great start but that's not enough,” Miff asserted. “It does not solve for any of those economics and closed-loop patient management areas. The technology element needs to be strongly considered not only from the hospital side, but how the technology can support the operations of the community-based organizations.”

This entails a connected and interoperable digital ecosystem, he said, that enables case management and follow-up. It also calls for a flexible front end that allows clinicians to view pertinent clinical information and community workers to view pertinent community information.

And at the end of the day, this means engaging community partners, like Miff discussed. Bringing each of them to the table as equal partners to the hospital or health system can spur on a program that fully works for all stakeholders.

And looking into the future, that multi-stakeholder approach will allow healthcare to personalize SDOH programming.

“The social determinants of health will remain to be critical as we understand needs across a group of patients or across a whole community,” Miff concluded. “But increasingly we need to really personalize that and really understand what drives an individual's health for multiple factors.”