The document discusses the importance of integrating social determinants of health (SDOH) data into healthcare workflows to improve patient outcomes and promote health equity. It highlights the need for standardized protocols, such as the PRAPARE framework, which allows healthcare systems to assess and link patients to community services based on their social and economic conditions. The report emphasizes that capturing SDOH data will drive better understanding and interventions for underserved populations, paving the way for improved healthcare delivery in a value-based payment system.

1. Social Determinants of Health:
Tools to Leverage Today’s Data Imperative

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Social Determinants of Health
This report is based on a 2018 Healthcare Analytics Summit (HAS 18)
presentation given by Andrew Hamilton, RN, BSN, MS, Chief Informatics
Officer and Deputy Director of AllianceChicago, entitled, “Standardizing the
Collection of Social and Economic Risk Data.”
Andrew Hamilton, RN, BSN, MS
Chief Informatics Officer, Deputy Director
AllianceChicago

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As value-based payment (VBP) puts more
pressure on health systems to reach quality
targets and lower the cost of care, healthcare
leaders are increasingly interested in
strategies to better understand health and
wellness in their populations.
Strategies that leverage social determinants
of health (SDOH) data are gaining attention
for their ability to paint a comprehensive
picture of health and address social and
economic risk by connecting patients in need
with the appropriated community services.
Healthcare Outcomes Improvement

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The World Health Organization defines
SDOH as, “the conditions in which people
are born, live, work, and age.”
It adds that money, power, and resources at
the global, national, and local levels shape
these conditions and that SDOH significantly
impact health inequities.
This presentation outlines the importance of
SDOH in healthcare today and offers an
example of a protocol for health systems to
standardize SDOH in their workflows.
Social Determinants of Health

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By capturing data on daily patient life,
socioeconomic and employment status,
environment, etc., SDOH data gives richer
insights into factors impacting health than
traditional healthcare encounters do.
This is an especially important
consideration with complex and
underserved populations.
Social Determinants of Health: A Requisite for
Delivery System and Payment Reform

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Other data sources, such as genetics and
healthcare delivery, can shed some light on
quality and patient experience, but because
patient choices are the biggest driver of
health outcomes, true understanding
demands a broader view.
SDOH data captures patient choices
and genuine experiences at a level
traditional health data sources
(which exist primarily within the
four walls of healthcare) cannot.
Social Determinants of Health: A Requisite for
Delivery System and Payment Reform

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Figure 1 shows a breakdown of actual health determinants, with patient
choices weighing in highest and just above genetics (30 versus 40 percent).
Social Determinants of Health: A Requisite for
Delivery System and Payment Reform
Figure 1: Health determinants

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Data elements for SDOH cover a range of daily life beyond the
healthcare delivery system:
Social Determinants of Health: A Requisite
for Delivery System and Payment Reform
Employment
Food insecurity
Housing
Financial strain
Utility needs
Education
Social support
Physical activity
Mental health
Substance abuse
Immigration
Exposure to violence
Transportation

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Figure 2 (next slide), a framework for health
equity, shows both the “upstream” SDOH,
or social-ecological, and the “downstream”
medical data models.
The goal of standardizing SDOH data is to
help health systems leverage both sides of
this diagram, ensuring incentivized and
sustainable services addressing SDOH as
well as integrated community partnerships.
Social Determinants of Health: A Requisite
for Delivery System and Payment Reform

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Social Determinants of Health: A Requisite
for Delivery System and Payment Reform
Figure 2: A framework for health equity

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Goals of Standardizing Data on Patient Social Risk
Health systems can achieve four central goals
by standardizing SDOH data within the EHR:
1. Improve health, lower cost, and advance health
equity (the overall goal).
2. Assess SDOH needs.
3. Link patients to community services.
4. Develop sustainable business models to
fund access to community services.

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Goals of Standardizing Data on Patient Social Risk
To meet these goals, health systems need an
SDOH strategy that will leverage data for risk
stratification as well as connect patients with
appropriate community services.
Doing so requires data interoperability,
common sets of values, and the capability to
harness SDOH data for analytic purposes.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
Healthcare organizations can benefit from following a
protocol for adopting SDOH into their workflows.
For example, the Protocol for Responding to
and Assessing Patients’ Assets, Risks and
Experiences (PRAPARE) is a standardized
patient risk assessment protocol that aims
to engage patients in assessing and
addressing SDOH.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
As described by Hamilton during his HAS 18
presentation, PRAPARE is a national effort and
collaboration between multiple organizations to
help health systems and other providers collect
and apply the data they need to better
understand their patients’ social and economic
risks, with the goal to transform care to meet
patient and population needs.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
PRAPARE addresses 15 questions to
assess 14 core SDOH domains.
The Uniform Data System (UDS) for
federal health center reporting already
addresses nine of these domains.
PRAPARE also has five non-UDS
domains, taken from Meaningful Use
Stage 3, and six optional domains
(Figure 3).
CORE
UDS SDH Domains
1. Race
2. Ethnicity
3. Veteran Status
4. Farmworker Status
5. English Proficiency
6. Income
7. Insurance
8. Neighborhood
9. Housing
Non-UDS SDH Domains
10. Education
11. Employment
12. Material Security
13. Social Integration
14. Stress
OPTIONAL
Non-UDS SDH Domains
1. Incarceration History
2. Transportation
3. Refugee Status
4. Country of Origin
5. Safety
6. Domestic violence Figure 3: PRAPARE domains

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
An effective standardized patient risk
assessment protocols for SDOH must
collect data at an individual level and use
that data at a population health level to
inform care coordination efforts.
The data must be accessible to clinicians
at the point of care and at a national
level to inform local, state, and national
delivery redesign.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
These protocols must meet key criteria:.
Are actionable at the patient and
population levels.
Include stakeholders in the
development and vetting
process.
Are integrated in the EHR to
facilitate assessments and
interventions.
Function as a patient-centered
conversation starter.
Have a common core yet are flexible to allow implementation
in various workflows, enable additional and more granular
questions and use with a combination of other tools/data.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
Organizations looking for an effective standardized
patient risk assessment protocol for SDOH will
enjoy more effective outcomes if they choose a
protocol with an implementation and action toolkit.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
The PRAPARE toolkit, for example, covers vital steps:
1. Understand the SDOH standardization project.
2. Engage key stakeholders.
3. Strategize the implementation process.
4. Carry out technical implementation with protocol-
provided EHR templates.
5. Develop workflow models.
6. Develop a data strategy.
7. Build capacity to respond to SDOH data.
8. Respond to SDOH data with interventions.
9. Track enabling services.

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An Effective SDOH Protocol Prioritizes Patient
and Population Health
During two years of pilot studies (2015 and 2017), PRAPARE
has met important performance targets:
• Easy to administer.
• Allows for implementation with various workflows
and staffing models.
• Builds patient-clinician relationships.
• Identifies new needs.
• Leverages targeting messaging and staff support.
• Facilitates collaboration with community partners.
• Leads to positive change at the patient, health center,
and community/population levels.

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Looking Ahead with SDOH Data
Standardization protocols for SDOH data are a necessary
place to start to integrate more patient social and
economic data into healthcare delivery.
As the industry moves toward greater health
equity, key questions remain about the role
of SDOH data moving forward.

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Looking Ahead with SDOH Data
The next steps will need to identify the best ways
to capture SDOH data (particularly for patients
who have not engaged with the healthcare system)
and use the data to inform the patient’s care plan.
Additional understanding will include the
correlation between specific SDOH and health
outcomes and which business models will support
sustainable and effective programs around SDOH.

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Looking Ahead with SDOH Data
Social and economic patient data will
continue to play a critical role in healthcare
as VBP further presses organizations to
raise quality and lower costs.
Health systems can best standardize SDOH
data in their workflows with a protocol that
includes relevant and comprehensive
domains, engages patients, enables
broader understanding of patient health,
integrates with organizational EHRs, and
is easy for clinicians to follow.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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Other Clinical Quality Improvement Resources
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