5 Key Strategies to Identify and Address Social Determinants of Health

To advance health equity, health plans and their vendors must first identify social determinants of health and then work to break down barriers to health for specific subpopulations, according to healthcare experts on a panel devoted to SDoH and MA.

Every stakeholder in the healthcare industry today has reasons to work toward health equity. First and foremost, it’s the right thing to do. Second, given the ever-rising costs of healthcare, it can help address emerging or potential health challenges before they become costly emergencies.  

The Centers for Disease Control defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.” Working toward health equity means looking at all the drivers that impact someone’s health; research shows that 80% of those factors take place outside of a medical setting: the ability to get nutritious food, access to reliable transportation, safe and affordable housing, freedom from environmental dangers, etc.  

Addressing social determinants of health was the focus of a panel at Strategic Solutions Network’s recent Medicare Advantage Leadership Innovations conference in Scottsdale, Arizona. The panel, which was moderated by executive editor of AIS Health, Lauren Flynn Kelly, and included Robbins Schrader, CEO and Founder of SafeRide Health, discussed ways that health plans and vendors can work together to break down barriers to health. Here are some of the key takeaways from the conference:  

1. Building Trust is Essential

In most cases, the best way to find out what is happening in a member’s life is by asking them. If they don’t feel respected, accepted, and heard, they’re unlikely to open up to a care provider or navigator. “We can't pick up the phone and say to the member, ‘Hey, did you eat yesterday?’” said Rachael Swan, EVP for Pyx Health, a technology company that combats loneliness. “The first question out of our mouths has to be, ‘How are you doing? Is there anything that I can help you with? How was your morning?’ And really understanding that it takes time to build that transformational relationship [rather than] a transactional one.” It’s important to build rapport and trust so members feel comfortable confiding about their challenges—and believe that you will help them overcome those challenges.

2. Member Assessment Is an Ongoing Need

A person’s life and health status can change quickly, so keeping up with their social determinants of health means taking every opportunity to assess how they’re doing. SafeRide Health is constantly gathering, verifying, and adjusting member data to provide the best service and insights about that person’s non-emergency medical transportation needs: How often they need transportation, what type of rides they need, who is booking their rides, what is covered by their plan, etc. “We take all those digital data points and run them back through our predictive analytics and through our AI to get smarter and smarter about the member,” said Schrader. “For us, member assessment is a forever thing. It's not a one-time thing.”

3. Don’t Just Gather Data: Use It (ASAP)

The most advanced data collection and predictive analytics are meaningless if they aren’t used to improve care and break down barriers. The ability to tangibly impact SDoH can also affect Star Ratings, especially given the new MA Health Equity Index, panelists said. “The writing on the wall from CMS and NCQA (National Center for Quality Assurance) is really clear that you can't just collect data. The requirements for the SNS-E HEDIS (Social Need Screening, Healthcare Data and Effectiveness Set) measure state that we must use a prescribed instrument, ask standard questions, and document both challenges and solutions using structure data such as Z-codes, LOINC, and SNOMED. Additionally, solutions need to be offered in a timely matter,” said Keslie Crichton, Chief Sales Officer of BeneLynk, which provides social care services to managed care plan members.  

“If you know a member has a transportation issue, assist that member within that same interaction, if possible,” Crichton said. “That's what’s going to really move the needle, solving their problem that day, not 30 days from now.” Companies like SafeRide Health, which provides innovative on-demand rides to plan members, can help make a real, immediate difference. “By creating new pathways and better pathways to holistically serve members, we’ve been able to deliver outsized results,” including grievance and fulfillment rates that are much better than the industry average, Schrader said.  

“We take all those digital data points and run them back through our predictive analytics and through our AI to get smarter and smarter about the member,” said Robbins Schrader, CEO and Founder of SafeRide Health. “For us, member assessment is a forever thing. It's not a one-time thing.”

4. Look for Non-Traditional Ways to Engage

Every member interaction—whether on the phone, virtually, or in person; in a doctor’s office or at their local YMCA—is an opportunity for a health plan and its vendors to find out about someone’s roadblocks to good health. Forging partnerships with innovative vendors and community organizations can create additional avenues to gather that information and help your members. “Every single interaction can be another way to move the ball down the field of that trust, so that when they do have a need, they come back to you, they trust you, they know you're going to close that loop for them,” Swan said. “And that’s really important across everybody that touches your members, from your providers all the way to your vendors.”  

5. Address Each Subpopulation at a Time

Improving health equity and addressing SDoH requires addressing one subpopulation at a time, rather than trying to solve every problem for all members. “We know that folks who may not qualify for duals but are in that lower income spectrum of the Medicare continuum have access issues—the more rural you are, if you have immigrant status. … [and] if we truly want to move the needle, we are going to have to figure out other ways to engage those populations that have historically been disenfranchised from the healthcare system,” said Karin VanZant, Vice President of SDoH and Health Equity for Clearlink Partners, a healthcare management consulting firm. “It [requires] being very strategic and almost surgical about the types of innovations or the types of programs that we’re putting in place for those populations that have much worse health outcomes.”  

While there is no one-size-fits-all solution to addressing social determinants of health, the panelists agreed that it will take both human skills and digital innovation to ensure that health plans move closer to achieving health equity.  

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