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Improving Access to Care and Outcomes Through Innovative SDoH Strategies

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Social and economic factors, such as a person’s financial stability, the home and neighborhood they live in, their access to quality education and affordable healthcare, and connection to community support all play essential roles in a “whole person” approach to health. Often referred to as social determinants of health (SDoH), the Robert Wood Johnson Foundation (RWJF) reports that these factors can determine as much as 80% of health outcomes. In their report Why Zip Codes Matter, RWJF noted that these social factors accounted for more than one-third of all deaths—more than smoking and obesity combined.

As health professionals well know, food insecurity correlates with higher levels of diabetes, hypertension, and heart failure; housing instability factors into lower treatment adherence; and transportation barriers result in missed appointments, delayed care, and lower medication compliance.

In a session on innovative SDoH strategies at the SHSMD Spectrum Connections conference last September, experts discussed how to use data to drive your hospital’s investment in SDoH-focused innovative care models that can meet the needs of your community.

“The data aspect, we have found, is critical in the whole process,” notes Lindsley Withey, FACHE, a Managing Director of the healthcare strategy consulting firm, BDC Advisors. “A market analysis helps you identify the areas of greatest need, pinpoint targeted zip codes and neighborhoods, and measure progress. Also essential is tying the analysis to the strategic priorities of the organization. No two organizations will be the same.”

Examples of unique criteria that may be used to identify your community population target include:

  • Demographic factors (Population, age, growth, insurance coverage, etc.)

  • Percentage of the population below or above a certain percentage of the federal poverty level

  • Life expectancy

  • Primary care or specialty care provider need

  • Socioeconomic needs (food, housing, education, etc.)

  • Mobility (public transportation, car ownership)

  • Emergency department visit frequency

  • Drive time to existing services

  • Healthcare expenditures

  • Access to technology

Withey cites several examples of hospitals using data to better align their SDoH initiatives with community needs. “I have worked with a variety of organizations throughout my career, including a large safety-net hospital that was planning substantial investments of capital across the system. They wanted to understand the greatest needs across their service area,” she recalls. “The team helped them identify and validate a significant need for integrating behavioral health with primary care, and future models of care were developed with that in mind.”

A key factor in choosing your data points, Withey notes, is picking elements that are measurable. “If you want to track your success, you need data components that can be monitored on at least an annual basis,” she adds.

Gaye Woods, who recently joined CommonSpirit Health, a 140-hospital system, as Vice President of Equity and Inclusion, cited several examples of data-driven efforts focused on SDoH areas from her previous position as the system director of community benefit at SCL Health (now Intermountain Health).

“Economic stability was a prioritized community health need for one of our hospitals,” she explains. “The program focused on leveraging a hyper-local purchasing strategy aimed at directing our internal spend toward particular supply chain categories that could offer increased opportunities for minority and women-owned businesses. Catering and Food Services offered that initial category opportunity. We set a spend goal, identified small businesses, and worked to share information about the initiative across the organization. The program has performed well and has opened additional purchasing categories for development.”

Laundry services provided another chance to contract with a local community-based organization that offers opportunities for people who are re-entering the community following incarceration.

“This partnership provided an added bonus as we were indirectly contributing to the development of alternative workforce pathways,” Woods says. Food insecurity is another SDoH area that is commonly prioritized by health systems, due to heightened community needs to access adequate, fresh, and nutritious foods. Numerous examples of strategies that are proving impactful to families are emerging, particularly when done in collaboration with community-based organizations such as food pantries, schools, and public health departments. Examples include community gardens, referral partnerships with food banks, and school-based food programs.

“One strategy employed by SCL Health involved redirecting unused food from our cafeterias to food insecure areas,” Woods says. “In partnership with our food service management company, we were able to take cafeteria prepared foods, flash freeze them for transport, and deliver them to community partner organizations.”

One organization serves seniors who are experiencing homelessness.

“It was wonderful to hear the comments from members of the community, who were elated with the freshness and quality of the food. They went from a diet of limited variety, to more meaningful and nutritious meal options.”

Additionally, the program has had a positive environmental impact, preventing more than 6,000 pounds of food waste. The flash-freezing effort also helped support local schools that were shut down during the COVID-19 pandemic in getting healthy meals to their students who relied on school-based food programs.

“A school-based cafeteria was able to prep the food, freeze it, and make it available for families to drive through and pick up multiple days’ worth of meals,” Woods recalls.

Effective Jan. 1, 2023, new and revised requirements to reduce healthcare disparities will apply to organizations in The Joint Commission’s ambulatory healthcare, behavioral healthcare and human services, critical access hospital, and hospital accreditation programs.

“This has ratcheted up the need for disparity-related data as a valuable point of insight,” Woods explains. “Use your data, understand the needs in your community, and prioritize those needs based on what the hospital can do directly and what can be done in partnership with community-based groups and even corporate partners. Act as a community convener and emphasize collective action. Hospitals don’t have to carry the ball alone, and they shouldn’t. The issues are far too complex for any one organization.”

© 2023 by the Society for Health Care Strategy and Market Development (SHSMD) of the American Hospital Association. This reprint is being used with permission from SHSMD. This publication, or parts thereof, may not be reproduced in any form without written permission from SHSMD.


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