Using Data to Address Individual and Community Social Determinants of Health

Failure to effectively address the social and behavioral determinants of health often limits service providers’ ability to achieve positive health outcomes.  While progress is being made to improve care coordination, these efforts do not typically include strategies to address the social determinants of their clients’ health. As a result, significant challenges impede improved health of individuals with chronic medical conditions and serious mental health and/or substance use disorders. 

 Through multiple collaborative improvement projects, the California Institute for Behavioral Health Solutions (CIBHS) supports safety net organizations  to take on these challenges.  Central to this work is supporting service organizations to gather, integrate and use indicators of physical health status, mental health recovery progress, community activation, and social conditions.  This includes setting up systems to track these indicators over time and to incorporate their gathering and use into service delivery workflows (both individual interactions and caseload/census management).

 This session explores the fundamental changes that facilitate use of this expanded data set into both care processes and system management.  Changes include: identifying the expanded data set (including recovery indicators and social determinants); adopting data collection and tracking capacity; formatting data for use in care processes; altering care processes to integrate data gathering and use; and, using data to identify population-based opportunities to address social determinants.  Learning from CIBHS improvement projects indicate that these changes will only lead to improved health outcomes if senior leadership, middle management, and front-line staff are equally engaged in the development and use of the expanded data set.