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SocialStudies
PoorHealthLinkedwithDropOutRates
PoorHealthLinkedwithDropOutRates
SocialDeterminantsofHealth(SDH)information:
the7thvitalsignwithintheEMR/caremanagementplatform
Agenda
1) Social Determinants of Health (SDH)
- What are they?
- Why are they important?
2) External SDH data sets availab...
80%Unaccounted for in the EMR or
care management platform
Agenda
1) Social Determinants of Health (SDH)
- What are they?
- Why are they important?
2) External SDH data sets availab...
Examples:
1) Pollen Counts
2) Food Deserts
3) Distance to PCP
4) Distance to Fitness Facilities
Examples:
1) Education Attainment
2) Income
3) Car Ownership
4) Ability to Pay
Examples:
1) Fitness Spend Index
2) Convenience Food Spending
3) Outdoor Enthusiast
4) Device Activity Monitoring
Precision
State / Region
County / MSA
ZIP Code
U.S. Census Tract
U.S. Census Block Group
Individual Household
Individual P...
Precision-Level: ZIPCode
ZIP Code: 27707
Median Household Income: $41,695
ZIP Code: 27713
Median Household Income: $57,755
Precision-Level: U.S.CensusBlockGroup
$59,107
$59,375
$68,438
$48,287
$30,291
$162,716
$89,874
$76,744 $48,281
$42,070
$21...
Precision-Level: U.S.CensusBlockGroup
$59,107
$59,375
$68,438
$48,287
$30,291
$162,716
$89,874
$76,744 $48,281
$42,070
$21...
Precision-Level: ZIPCode
ZIP Code: 27707
Median Household Income: $41,695
ZIP Code: 27713
Median Household Income: $57,755...
Precision-Level: Person/Household
Affordability Issues No Affordability Issues
$59,107
$59,375
$68,438
$48,287
$30,291
$89...
Precision
State / Region
County / MSA
ZIP Code
U.S. Census Tract
U.S. Census Block Group
Individual Household
Individual P...
Precision
State / Region
County / MSA
ZIP Code
U.S. Census Tract
U.S. Census Block Group
Individual Household
Individual P...
Agenda
1) Social Determinants of Health (SDH)
- What are they?
- Why are they important?
2) External SDH data sets availab...
CanSocialDeterminantsofHealth(SDH)informationbecome
the7thvitalsignwithintheEMR/caremanagementplatform?
The costs of adding social and
behavioral domains to EHRs, such
as programming, modifying
workflows, and intervening on
po...
Methodology
Your EMR/
Care Mgmt
Agenda
1) Social Determinants of Health (SDH)
- What are they?
- Why are they important?
2) External SDH data sets availab...
Actionability
PrecisionLevel
Where?
Who? Who Else?
Where Else?
SDHMaturityQuadrant
Hospital/ACO Planners Clinicians/Care T...
Where?
High Number Flu Cases
Flu Vaccine Clinics
Where
else?
ZIP Codes in Need of
Mobile Flu Clinics
Who?
ED Super-utilizers
Patient Specific Recommendations
28
Who
else?
The patient may need transportation
assistance to the hospital or pharmacy.
...
Dr. Brian P. Goldstein
EVP and COO of University of North Carolina (UNC) Hospitals
Member of Forecast Health’s Board of Di...
Actionability
PrecisionLevel
Where?
Who? Who Else?
Where Else?
SDHMaturityQuadrant
Hospital/ACO Planners Clinicians/Care T...
Methodology
Your EMR/
Care Mgmt
NEXT STEPS
Contact info:
Sohayla Pruitt, M.A.
Sohayla.Pruitt@forecasthealth.com
(919) 699-7424
Michael Cousins, Ph.D.
mcou...
Forecast Health's Social Determinants of Health Webinar
Forecast Health's Social Determinants of Health Webinar
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Forecast Health's Social Determinants of Health Webinar

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Social Determinant of Health Webinar for ACOs held on March 1, 2016 by Forecast Health.

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Forecast Health's Social Determinants of Health Webinar

  1. 1. SocialStudies
  2. 2. PoorHealthLinkedwithDropOutRates
  3. 3. PoorHealthLinkedwithDropOutRates
  4. 4. SocialDeterminantsofHealth(SDH)information: the7thvitalsignwithintheEMR/caremanagementplatform
  5. 5. Agenda 1) Social Determinants of Health (SDH) - What are they? - Why are they important? 2) External SDH data sets available - What are examples? - What’s the definition and importance of Precision? 3) Making SDH information the 7th Vital Sign - What are the challenges? - Why is that challenging? 4) A Road Map to actionable SDH information - What do you need? - How do you get it?
  6. 6. 80%Unaccounted for in the EMR or care management platform
  7. 7. Agenda 1) Social Determinants of Health (SDH) - What are they? - Why are they important? 2) External SDH data sets available - What are examples? - What’s the definition and importance of Precision? 3) Making SDH information the 7th Vital Sign - What are the challenges? - Why is that challenging? 4) A Road Map to actionable SDH information - What do you need? - How do you get it?
  8. 8. Examples: 1) Pollen Counts 2) Food Deserts 3) Distance to PCP 4) Distance to Fitness Facilities
  9. 9. Examples: 1) Education Attainment 2) Income 3) Car Ownership 4) Ability to Pay
  10. 10. Examples: 1) Fitness Spend Index 2) Convenience Food Spending 3) Outdoor Enthusiast 4) Device Activity Monitoring
  11. 11. Precision State / Region County / MSA ZIP Code U.S. Census Tract U.S. Census Block Group Individual Household Individual Person LevelsofSDHPrecision High Low 1 2 3 4 5 6 7
  12. 12. Precision-Level: ZIPCode ZIP Code: 27707 Median Household Income: $41,695 ZIP Code: 27713 Median Household Income: $57,755
  13. 13. Precision-Level: U.S.CensusBlockGroup $59,107 $59,375 $68,438 $48,287 $30,291 $162,716 $89,874 $76,744 $48,281 $42,070 $21,567 $39,643 $38,500 $36,840 $45,643 $39,083
  14. 14. Precision-Level: U.S.CensusBlockGroup $59,107 $59,375 $68,438 $48,287 $30,291 $162,716 $89,874 $76,744 $48,281 $42,070 $21,567 $39,643 $38,500 $36,840 $45,643 $39,083
  15. 15. Precision-Level: ZIPCode ZIP Code: 27707 Median Household Income: $41,695 ZIP Code: 27713 Median Household Income: $57,755 $162,716
  16. 16. Precision-Level: Person/Household Affordability Issues No Affordability Issues $59,107 $59,375 $68,438 $48,287 $30,291 $89,874 $76,744 $48,281 $42,070 $21,567 $39,643 $38,500 $36,840 $45,643 $39,083 $162,716
  17. 17. Precision State / Region County / MSA ZIP Code U.S. Census Tract U.S. Census Block Group Individual Household Individual Person MultipleLevelsofSDHPrecision High Low 1 2 3 4 5 6 7
  18. 18. Precision State / Region County / MSA ZIP Code U.S. Census Tract U.S. Census Block Group Individual Household Individual Person LevelsofSDHPrecision High Low 1 2 3 4 5 6 7
  19. 19. Agenda 1) Social Determinants of Health (SDH) - What are they? - Why are they important? 2) External SDH data sets available - What are examples? - What’s the definition and importance of Precision? 3) Making SDH information the 7th Vital Sign - What are the challenges? - Why is that challenging? 4) A Road Map to actionable SDH information - What do you need? - How do you get it?
  20. 20. CanSocialDeterminantsofHealth(SDH)informationbecome the7thvitalsignwithintheEMR/caremanagementplatform?
  21. 21. The costs of adding social and behavioral domains to EHRs, such as programming, modifying workflows, and intervening on positive screens often fall on the individual health practice or hospital. The movement toward population health management and ACOs may address this malalignment over time. In the meantime, costs remain a barrier.
  22. 22. Methodology Your EMR/ Care Mgmt
  23. 23. Agenda 1) Social Determinants of Health (SDH) - What are they? - Why are they important? 2) External SDH data sets available - What are examples? - What’s the definition and importance of Precision? 3) Making SDH information the 7th Vital Sign - What does this mean? - Why is this important? 4) A Road Map to actionable SDH information - What do you need? - How do you get it?
  24. 24. Actionability PrecisionLevel Where? Who? Who Else? Where Else? SDHMaturityQuadrant Hospital/ACO Planners Clinicians/Care Team General Marketing Community Planners 12 4 3 7 6 5 4 3 2 1 See Do
  25. 25. Where? High Number Flu Cases Flu Vaccine Clinics
  26. 26. Where else? ZIP Codes in Need of Mobile Flu Clinics
  27. 27. Who? ED Super-utilizers
  28. 28. Patient Specific Recommendations 28 Who else? The patient may need transportation assistance to the hospital or pharmacy. The patient is experiencing financial difficulty and may not be able to afford prescriptions or follow-up care. The patient is seeing many providers and may have issues with care coordination. The patient is at high risk for medication non-adherence and may need counseling or follow-up. The patient is experiencing financial difficulty and may not be able to afford prescriptions or follow-up care.
  29. 29. Dr. Brian P. Goldstein EVP and COO of University of North Carolina (UNC) Hospitals Member of Forecast Health’s Board of Directors Forecast Health’s predictive models are highly accurate and identifies patient-specific risk factors. This means that if a patient’s risk arises from affordability issues, we’d know to provide extra medications from the pharmacy stockroom. With this, Forecast Health helps to provide higher quality care.
  30. 30. Actionability PrecisionLevel Where? Who? Who Else? Where Else? SDHMaturityQuadrant Hospital/ACO Planners Clinicians/Care Team General Marketing Community Planners 12 4 3 7 6 5 4 3 2 1 See Do
  31. 31. Methodology Your EMR/ Care Mgmt
  32. 32. NEXT STEPS Contact info: Sohayla Pruitt, M.A. Sohayla.Pruitt@forecasthealth.com (919) 699-7424 Michael Cousins, Ph.D. mcousins@forecasthealth.com (804) 380-8616 Thank you! www.forecasthealth.com

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