Social Determinants of Health — Moving Health Systems Closer to Value-Based Care
By Lindsey Getz
Social Work Today
Vol. 20 No. 4 P. 12

Including social determinants of health in the fabric of the health care system may be the big push needed to achieve value-based care. Toward that end, the health information technology industry is taking note of the key role social workers play in data collection and management.

As health care moves toward value-based care, the need to better address social determinants of health (SDOH) has gotten the spotlight. There is no question that SDOH can have a significant impact on both patient care as well as patient outcomes and they can no longer be left in the background for social workers to address after there has already been a negative health impact by unmet needs.

SDOH must be moved to the forefront to be addressed more efficiently and effectively in the health care setting.

Recently, there has been some key movement. In December 2019, Congress’ first bill to launch a multiagency council and fund $25 million in grants for the Social Determinants Accelerator Act was introduced. This action, along with increasing health care reform pressure, are undoubtedly driving things forward. Most say this is a long-awaited change.

Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, principal of EFS Supervision Strategies and industry subject matter expert on the SDOH says that organizations have wasted significant dollars by ignoring SDOH in the past.

“According to one study, SDOH are responsible for 50% of hospital readmissions,” Fink-Samnick says. “That a staggering number—but no social worker is surprised by that. The truth is social workers have long known the impact that SDOH have on hospital visits—and health in general—and the health care system as a whole is now catching up. Of course, as we move forward in determining the best way to incorporate SDOH into health care in order to elevate care, there are a lot of questions that are left to be answered. There’s no question it will take involvement across the board.”

That means a multifaceted effort that incorporates not only physicians and hospitals but also insurance providers and even health tech startups—who have an opportunity to help integrate SDOH into health care utilizing health information technology.

At the Insurer Level
There has certainly been some movement from insurers. Florida Blue, part of the Blue Cross and Blue Shield Association, has hired social workers at walk-in centers it owns across the state in order to better address SDOH. Florida Blue Centers are a physical location where health plan members can come in and discuss their bills, visit with a nurse, and even participate in wellness classes. These centers are operated by GuideWell Connect, a subsidiary of the holding company GuideWell, which also serves as the parent company of Florida Blue.

According to Sarah Iselin, MS, executive vice president of government programs and diversified business for Florida Blue, they—and GuideWell—have long recognized that health stems beyond the balance of a traditional health care system which has been a guiding principle of the centers in the first place. It only makes sense to extend that effort to also address SDOH.

“We understand that it is hard to maintain good health if you do not have access to healthy food, child care, or affordable housing,” Iselin says. “If you have a chronic condition but no transportation to doctor appointments, it’s difficult to manage that condition. These are issues we recognize need to be addressed. We take a holistic approach to helping people—it’s part of our mission. So, putting social workers—who we refer to as community specialists—into our centers just makes sense. It also aligns with our mission.”

Currently, Florida Blue has social workers in 18 of their centers and they’re available to support anyone who walks in the door—something that Iselin calls “an extension of our commitment to the community.” Considering these centers have become a critical lifeline for some, the fear of cutting off that access as a result of the COVID-19 pandemic was a legitimate concern when quarantine orders were put into action. Fortunately, the centers were able to make an easy transition into the virtual realm. And that’s a good thing, as Iselin says the need for the centers has become “even more relevant with the spread of COVID-19.”

“The need to connect people to community resources has never been more important than it is right now,” she says. “We are connecting people to food programs or issuing referrals to mental health resources or employment agencies. So many people have lost jobs and the need to access food is in the spotlight. We are leveraging technology to make that possible.”

Digitization of Social Needs
Perhaps now, more than ever before, the use of technology—as well as ways in which technology can help integrate SDOH into health care—is receiving attention.

Sandeep Wadhwa, MD, MBA, chief health officer and senior vice president of market innovation for Solera Health, a company that connects customers with evidence-based, nonmedical wellness programs, says that digitization of social needs and barriers has remained one of the biggest roadblocks to ensuring SDOH are well integrated into the health care system. In May 2019, the Phoenix-based company announced that it had raised $42 million to help integrate SDOH and evidence-based community health interventions into health care. This would allow health plans to pay social services providers through the same pathway that other health care providers are reimbursed.

But Wadhwa says that digitization remains an issue that requires more attention.

“We have digitized so many sectors—most recently, digitizing electronic health records—so I think digitizing social work and having data that interoperates with other sectors is the next step,” Wadhwa says. “This is where we are seeing quite a few tech efforts being made. It’s about an electronic record that would be visible across an entire care ecosystem.”

It’s an area where many tech companies are investing resources. For one, Netsmart, an information technology partner to human services and postacute health services providers and organizations, has been looking at ways in which SDOH can be addressed through data sharing and care coordination.

“Having a method to document that information in a way that it is both accessible and actionable is key,” says Julie Hiett, MSW, senior director of population health for Netsmart. “For example, a real-time alert based on new SDOH information or auto-tasking a care coordinator could give providers vital information if there is an issue that needs to be addressed.”

Hiett says that having better solutions for sharing information will ensure that more individuals’ needs are being met.

“The fact is, if a doctor provides you with a medication but you don’t have a way to pay for it, it’s not going to do much good,” she adds. “We need to connect these social determinants directly to a person’s health chart if we truly want to see the benefits.”

Neal Tilghman, MPA, general manager of behavioral health for Netsmart says that sharing information is something that has always been done manually—but increasing the efficiency and connectivity through technology could be monumental in ensuring that SDOH are not overlooked.

“Knowing that someone is food insecure or has another social determinant that could be impacting their health is critical—and we’ve been sharing this information via verbal communication for decades,” he says. “But we’ve never had the technology to truly make that data real-time. Tools that will allow us to interact with data in real time will be a gamechanger.”

ConsejoSano, which provides a patient engagement platform and health care data analytics tailored to help providers and payers increase engagement with multicultural groups is another tech company looking at not only SDOH but also what they term “cultural determinants of health.”

“The country has become increasingly multicultural and that has created a mismatch between the health system that the United States has built and the population that it can serve,” says ConsejoSano founder and CEO Abner Mason, explaining the problems from which ConsejoSano was born. “The country has changed, and if we’re going to serve the America that we’ve become, then we need to change our health care system. We’re using technology to do that.”

Mason says that just in the way that other social determinants like housing and income impact one’s health, their cultural background does, too. These cultural determinants must also be addressed in order to ensure health needs are met. Otherwise cultural barriers will remain in the way of people fully accessing health care.

As a result of COVID-19, this is more evident than ever.

“The coronavirus crisis has been called the ‘Great Equalizer,’ as it is a virus that is impacting everyone,” Mason says. “However, I would call it the ‘Great Revealer,’ as it’s bringing to light the structural problems that already existed within our society and our health care system. As we are seeing the virus have an impact on certain communities in a disproportionate way, we are realizing it’s not just the result of COVID-19 but the result of a health care system that does not serve all Americans.”

Mason says that this is an opportunity to be proactive in taking steps toward better addressing SDOH, including cultural implications.

“We can’t go back to using the same old approaches, as they’ve failed us,” he adds. “In order to truly be able to address SDOH, we need to bring in community-based organizations and social workers who understand these populations—and the community at large. But that means supporting these organizations and the social workers who started them or often run them. Right now, I see community organizations as a huge part of the solution, but the problem is funding.”

Wadhwa agrees. Currently, social workers are not reimbursed the way other medical providers are, despite their role in the health care system as a whole. A huge key is the data being produced as we face necessary changes. Wadhwa adds there are currently two benefits being tracked—economics and effectiveness.

“It’s this idea that an ounce of prevention is worth a pound of cure,” Wadhwa says. “And I think with that, most people are looking at cost savings. But I am more interested in the health improvement impacts this can have on the community. Are we actually producing healthier outcomes? I think if we are going to invest insurance dollars into this, it should come down to measuring the health improvements. Otherwise, why should a health insurance dollar go to social services as opposed to just spending more on traditional health care services? I think we need to be able to show that this is promoting population health improvements.”

This is something that Solera has already been looking at with its lens focused specifically on financial literacy, social isolation, and food insecurity. Wadhwa says that these areas have evidence-based backing around a reasonable expectation of improving health status when addressed.

“At Solera, we are interested in supporting evidence-based interventions that can improve health status,” he says. “We organize ecosystems of intervention and have already launched a program addressing social isolation.”

Wadhwa says that social workers play a critical role in the overall fabric of care and in these intervention efforts.

“I am already seeing more health plans invest in social workers, and I believe we’ll see that role expanded,” he says. “I think there’s a recognition that social workers have already been leaders in addressing SDOH. As we move into new models of care that are digitized and interoperable, social workers will be at the helm.”

Addressing Interconnectivity
But lack of interconnectivity remains a viable barrier.

“When a social worker is using one system and a doctor or other provider is using another—there’s an obvious disconnect there,” Hiett says. “So, we need to standardize the data sharing to pull the information together so that it can be shared.”

Hiett says that Netsmart’s CareManager product is one solution addressing this problem.

Fink-Samnick agrees that interconnectivity may be the biggest hurdle to overcome.

“The fact is, no single product will do it all,” she says. “The case management community wants something that can connect all aspects of a patient’s health history, including SDOH, but the only way we’ve seen this done is through a series of platforms—not one single product. And there remains the challenge that many social service agencies lack access to technology—or funding for technology. So, there’s still a lot to overcome.”

Sean Erreger, LCSW, MSW, author of the Stuck on Social Work blog and an adjunct instructor at the University of Buffalo School of Social Work, says that the idea of being able to make referrals in a way that reduces duplication, allows for progress to be tracked, and increases efficiency is incredibly valuable from a case manager standpoint.

“It’s a matter of being able to use technology to execute a referral and then track that referral in a way that keeps the information at the tip of my fingertips. That could mean getting people resources quickly instead of calling around to a bunch of places and checking a bunch of websites. A lot of case management work is redundant and using up time that could be otherwise used to be helping people. If we can use technology to better connect people to resources, it would be a gamechanger.”

Erreger says he sees a lot of tech companies doing great things in the space. But he agrees there’s a long way to go.

“The reality of this—the drawback—is that managing all of that data is a massive undertaking,” he says. “As just one example, who is making sure that the food pantries in our database are still operating and able to take new referrals? If you’re going to use technology to refer someone to a social service that they need, you have to make sure that all of those resources are also connected within the system. That’s no small feat. In theory, I fully welcome using technology to improve our efficiencies. In reality, I know it could take time—but I still believe we’re moving in the right direction.”

— Lindsey Getz is a Royersford, PA–based freelance writer.