Best practices in collecting and using data on the social determinants of health to inform care, public health partnerships, and policy

Millions of people, particularly medically underserved populations, face social determinants of health (SDH) that influence their health.  To ultimately reduce health disparities and improve health, providers need to more fully understand their patient populations and provide them with more appropriate services to meet both their clinical and non-clinical needs.  To address this gap in knowledge, the National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, and Institute for Alternative Futures developed an evidence-based and consensus-driven patient risk assessment tool that includes validated measures related to race and ethnicity, veteran status, English proficiency, income, insurance, residence, education, employment, material security, housing status, social integration, stress, transportation, and incarceration history.  These measures align with the Institute of Medicine’s Report on “Capturing Social and Behavioral Domains in Electronic Health Records (EHRs)”.

In 2015, four health centers and health center networks pilot-tested the tool and implemented it in their workflow, developed EHR templates, developed interventions to address the SDH, and cross-tabulated SDH measures with outcomes measures, costs, and utilization data to identify which factors are driving higher health care costs and poorer health outcomes. 

This presentation will present the tool but mainly focus on implementing, using, and disseminating the tool, such as training staff and altering workflow to collect new data, messaging the tool to patients, using data to address SDH through interventions, such as enhanced clinical care, access to non-clinical services, and community partnerships, and using cross-tabulated data to inform policies, such as payment reform and risk adjustment methodologies.