The Best Path Forward | Journal Of AHIMA

The Best Path Forward | Journal Of AHIMA


By Joe Nicholson, DO

“Business as usual.” Hopefully, the COVID-19 pandemic has erased that phrase from our lexicon forever. After all, what does it mean?

For healthcare professionals, “business as usual” too often involves transactional, fragmented experiences somewhat divorced from patients’ everyday lives. Providers routinely suggest patients adopt healthier diets, for example, without ever knowing whether those patients have access to healthy food. People exposed to COVID-19 are advised to self-isolate, but what if they live in a tiny two-bedroom apartment with six other individuals?

COVID-19 has exposed many reasons why “health care as usual” must evolve to be more flexible, inventive, and human-focused. It has illustrated with eye-opening clarity the enormous influence of social determinants of health (SDOH). It has also highlighted both the clinical and financial downsides of transactional, fee-for-service (FFS) models. In fact, in many ways, the pandemic has verified the efficacy of data-driven, value-based care (VBC). Over the past months, providers already steeped in VBC have proven that the risk can be worth the reward.

That is because VBC agreements stabilize reimbursement and reward healthcare organizations for proactively managing SDOH to alleviate clinically and financially costly conditions. Consequently, providers in VBC arrangements had the flexibility needed to be as creative as necessary to keep their patients healthy. They demonstrated that the “whole person” care enabled by focusing on SDOH, with the support of data-driven VBC, puts the “Quadruple Aim” within reach.

So, what does that mean for healthcare in the future? I believe the entire industry has learned three key lessons we should take to heart:

  1. SDOH and VBC are inexorably intertwined. Together, they can have an undeniably positive impact on public health.
  2. Successful outcomes require aligned partnerships and collaboration. The healthcare system alone has much less effect on health outcomes than we sometimes like to admit. Tackling SDOH is one of those “it takes a village” efforts.
  3. Nontraditional data is crucial. The most valuable data and resources are often found outside the health system. To truly gain a holistic, 360-degree patient view requires the assistance of health information (HI) professionals to harness nontraditional data.
Successful VBC Needs SDOH Data

Here’s a story that beautifully illustrates the direction healthcare should continue moving toward:

During the COVID-19 quarantines, a community health advocate team I work with in south Texas quickly realized that many of the community’s elderly adults were experiencing social isolation, difficulties accessing food and support services, and other SDOH challenges. So, they began to screen and identify patients at risk for SDOH barriers. Within two days, they created a COVID-19 emergency outreach protocol (resources, outreach criteria, and procedures) and began calling vulnerable Medicare patients to connect them with community support services.

The benefit to patients’ lives was immediate and gratifying. In addition to the very human return on investment, the team also anticipates a financial return through their value-based contracts. They believe the proactive outreach will improve their Medicare star rating and bonus targets and allow them to achieve cost savings by reducing potential medical costs due to delayed care.

What’s noteworthy about this endeavor is the speed with which the team used its data to stratify patients’ SDOH risk. Then, with that intelligence, they worked proactively to mitigate potential health issues.

They understood that SDOH disparities such as lower socioeconomic status raise the risk of costly conditions such as diabetes.1 In fact, peer-reviewed evidence increasingly shows that more than 80 percent of the factors that influence health outcomes fall outside the realm of clinical care.2 Those factors include a safe home environment, financial and food security, transportation, access to clean water and clean air, and access to medications, among others.

These aren’t new revelations, of course. Disparities have been studied and discussed in the US for nearly 40 years.3 Until now, however, we haven’t had the reimbursement models or the data to address SDOH.

Data is not only crucial; it’s also one of the biggest challenges we face. Think about all of the data sources typically leveraged in health systems every day. How many of them come from within the health system or its immediate business partners (e.g., insurance companies)? While those data sources are a great start, providers need a more connected view of nontraditional data to attend to SDOH adequately.

The only way to obtain a fully patient-centered view of patient populations is to capture, exchange, and analyze data from nontraditional sources such as:

  • Community groups, especially “safety-net” organizations such as the shelters and food banks that have seen unprecedented utilization during the pandemic.
  • Telemedicine platforms and wearable devices, which have become tremendously popular as socially distant supplements to in-person care.

In addition, it has become increasingly evident that physical and mental health data can no longer exist in silos. The ability to address mental health conditions such as anxiety or depression can substantially impact health and financial outcomes.4,5

COVID-19 has made a case for better population risk stratification by integrating and normalizing multiple data sources, including census data, consumer data, health claims data, home health insights, and both physical health provider and mental health provider/electronic health record (EHR) data (including Z codes). HI professionals have the expertise to help develop strategies to integrate internal, external, structured, and unstructured data to give providers the holistic views they need to provide whole-person care.

The Role of HI Professionals

HI professionals can play a central role in identifying and prioritizing patients whose health could be affected by SDOH. However, they need tools that ask the right questions and capture the right data.

Many patients don’t make the connection between SDOH barriers and their health. So, to accurately capture that data, HI professionals may want to encourage the use of validated screening tools that identify SDOH barriers. One such tool is the PRAPARE assessment.6 (PRAPARE stands for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. It is specifically designed to help providers collect actionable SDOH data.)

With such data in hand, HI professionals, information technology teams, and analytics teams can work alongside clinicians to take a two-pronged approach to interventions:

  • Proactive: Teams can develop a predictive score that identifies patients at high risk for SDOH barriers. The risk stratification then can be used to direct proactive patient outreach.
  • During visits: Teams can create tools to be used during patient visits to evaluate and score SDOH needs and barriers. After each patient encounter, the insights can be used to guide appropriate follow-up interventions (e.g., telephonic follow-ups, resource mailings, etc.).

Likewise, HI professionals can also help strengthen bonds with community-based organizations by building data tracking and reporting efficiencies. For instance, HI professionals could be instrumental in developing processes to:

  • Capture and exchange interdepartmental SDOH data (e.g., pharmacy, respiratory, case management).
  • Capture and exchange SDOH data with community-based organizations.
  • Track SDOH interventions.
  • Create measurement standards and measure outcomes.

One Texas independent physician association (IPA), for example, recently undertook a program designed to recognize and address the SDOH affecting patients in its region. It leveraged its HI and data analytics teams, as well as its existing relationships with patients, health plans, community resources, and an organization that has spent more than 20 years working with providers to meet VBC goals. Together with its partners, the IPA used tools and algorithms to collect data and predict patients at risk for SDOH gaps. Then, they connected those patients with an interdisciplinary care team that included nurses, pharmacists, social workers, dieticians, health equity consultants, and others. As a result, they were able to track gap closures, improve health outcomes, and generate positive program ROI.

SDOH Drives VBC and the Quadruple Aim

Healthcare has spent years trying to define and accomplish the Quadruple Aim. COVID-19 has confirmed that VBC is an ideal method to achieve it, but VBC, in turn, requires a commitment to solving SDOH obstacles. As the earlier examples of the Texas IPA and the community health advocate team demonstrate, proactively addressing SDOH helps meet each objective of the Quadruple Aim. It:

  • Lowers costs by reducing unnecessary emergency department visits, admissions/readmissions, and office visits.
  • Improves patient outcomes through reduced social and environmental barriers that in turn can enhance care coordination, raise health literacy, and boost medication adherence.
  • Increases patient satisfaction through more frequent interactions with social services providers and better management of SDOH to care for the whole person.
  • Increases provider satisfaction by promoting better patient care and more substantial community benefits.

However, none of this is possible without HI professionals helping drive a collaborative approach to robust, 360-degree SDOH data and analysis.

COVID-19 has taught us that we can improve outcomes when we break out of “business as usual” and instead focus on SDOH with the support of VBC. Our goal after the pandemic shouldn’t be to return to normal—or even to a new normal. Our goal should be nothing short of delivering more innovative and compassionate whole-person care.

  1. Centers for Disease Control and Prevention. Disparities in the Prevalence of Diagnosed Diabetes — United States, 1999–2002 and 2011–2014. November 18, 2016.
  2. Hood, Carlyn M. et al. “County Health Rankings: Relationships Between Determinant Factors and Health Outcomes.” American Journal of Preventive Medicine. February 2016.
  3. Heckler, Margaret M. “Report of Secretary’s Task Force on Black and Minority Health.” U.S. Department of Health and Human Services. 1985.
  4. Niles, Andrea N., O’Donovan, Aoife. “Comparing anxiety and depression to obesity and smoking as predictors of major medical illnesses and somatic symptoms.” Health Psychology, 38(2), 172–181.
  5. Davenport, Stoddard et al. “Potential economic impact of integrated medical-behavioral healthcare: Updated projections for 2017.” Milliman. February 12, 2018.
  6. National Association of Community Health Centers. The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.

Joe Nicholson, DO, is the chief medical officer at CareAllies.

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