There are a variety of non-clinical factors that keep your members from getting the care they really need. Learn more about why SDOH should be a priority for your company this year.
Searches for “social determinants of health” have swelled tremendously since the early 2000s, and for good reason. But what exactly are social determinants of health?
This is a graph that shows search frequency and interest for “social determinants of health” from 2004 to the present.
Some real-life examples of social determinants of health are:
As defined by the Department of Health and Human Services, social determinants of health “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Today we’ll go over:
What Are The Different Social Determinants of Health?There are several different models of SDOH out there, however, to keep things simple, we’ll distill them into five groups:
The Healthy People 2030 Framework And What You Need To KnowThere are more than 500 data points and objectives that the government has outlined to measure the health of Americans. The goal of these initiatives is to “Create social, physical, and economic environments that promote attaining the full potential for health and wellbeing for all.”
One top-of-mind model of these disparities is the ongoing COVID-19 pandemic. Not all pandemic care is created equal. Millions of family caregivers are unable to access the care that they need while balancing work and care responsibilities, while many older adults are sequestered in long-term care settings unable to see loved ones.
This isn’t just a trend or buzzword—it’s a new evolution of care that’s taking flight. CMS even issued a roadmap for states to address SDOH through value-based reimbursement last year for Medicaid and CHIP (Children’s Health Insurance Program) programs.
One of the more startling truths they shared was: “The United States spends more on health care than almost any other country yet often underperforms on key health indicators including life expectancy, reducing chronic heart disease, and maternal and infant mortality rates.”
In order to stand out and differentiate your health plans from those of other companies, you need to demonstrate a commitment to lowering barriers to accessing needed care. Empower your members to take charge of their own health—without the mess and confusion of the system at large.
Why SDOH Should Be A Priority For Your Health Plan
We sat down with Michael Newell, the owner of Lifespan Care Management, and former nursing school instructor, who has a wealth of experience seeing first-hand the impact of social determinants of health:
Why are there large disparities in how healthcare spending is spread out across populations?
“If you’re managing a population, the 80/20 rule comes to play here. 10-20% of your subscribers account for 80-90% of your actual costs, everyone else is fine. You want to have a strategy to address that 10-20%. In certain populations it’s even worse, 1% can be 30% of the costs.”
Why haven’t SDOH historically been addressed? How does cost play into that?
“When you pay attention to [the cost], SDOH is a big issue: housing, safety, access to care, access to food, social support, things like that. That is opposed to the training of physicians (you don’t want to ask them anything other than symptoms) so what are we doing here? Modern American medicine has modern strategies to address symptoms but not the cause. If we don’t address the cause, we’re not going to have a chance for a cure or appropriate care. Appropriate in my mind, is what actually works:
How could improved physician training work to address SDOH?
“If we have a sense of what factors are getting in the way of stabilizing health problems, identify the 10-20% that have chronic health problems. We’re not addressing symptoms because we don’t know the full problem. Doctors haven’t been socialized to find out what’s behind the problem and the issues that arise when people come in seeking care.
Patient: I have pain.
Doctor’s response: Let me give you some pills.
What doctors should instead be asking:
How does language play a role in health outcomes?
If you really listen to that person (which along the way, they’ll identify their SDOH that are getting in the way of their normal functioning role) the SDOH will manifest itself in terms of symptom etiology and ability to self-care, engage in treatments, and follow instructions.
What we’re saying when a patient isn’t ‘compliant’ is that it infers that they don’t want to get better, they don’t want to do the right thing. They want to do the right thing, and they want to be liked and respected by their provider. If we have an attitude of 'they’re noncompliant,’ and that’s not helpful for anyone.
They’ll pick up on that attitude and decide if they want to fill that prescription. I like the term adherent because it doesn’t connote the blame on the patient. When people aren’t adherent, they might not understand the import of the instructions for various reasons, or they ran out of bandwidth, or perhaps you wrote it down in a way that they can’t understand or recall how to take a medication.”
Newell urges health plans to play an active role in managing benefits. Make sure that treatments that members receive are in their best interest, and are explained to them in a way that they understand.
TIP: Invest in community health workers, and train them in SDOH, to laser focus on your members, with a special focus on high-risk populations to layer in preventative care measures, before small concerns turn into expensive ER visits.
What Steps You Can Take Today To Improve Your Members’ SDOH
CMS is recognizing the outdated nature of fee-for-service payment models and has shifted toward value-based reimbursement models for many essential healthcare services. This means that you are going to be subject to this in the not-too-distant future.
Today, we’re going to share a few tips on how you can incorporate social determinants of health into your members’ plans today:
Each member’s care needs to be considered within their demographics, their career, their family, and their beliefs. When asking members to assess their experience, make sure that you take their context into account, and demonstrate that you care about them on an individual level.
Reminder: Health outcomes are not just tied to direct care, they’re also affected by diet, exercise, along with social and economic factors.
Moving Toward SDOH Is A Step In The Right Direction.Social determinants of health are a great way to assess your plans for efficacy and health equity. By following these tips, you’ll be able to make sure that your members are taken care of from head to toe.
One solution that can help you streamline social determinants of health with your members and their plans, is by checking out our SDOH solution within the QCSS data collector. Lean on a data-driven approach that improves the efficiency of your front-line clinicians.
Which one of these tips are you looking at trying today?
There are many different processes that can be used to determine the necessity, appropriateness, and efficiency of healthcare services. In the managed care model, it is important to have an effective Utilization Management (UM) program because it enables health plans and community organizations to ensure that they are managing the cost of services appropriately as compared to the capitation rate.
Why prospective review in Long Term Services and Supports?
A case-by-case prospective review is the most important type of Utilization Management process within the MLTSS setting of care for several reasons:
Key Strategies for Implementing Utilization Management
The strength of a organization's analytical capabilities directly translates to the success of their Utilization Management program and financial results.
Financial risk is the burden of health plans in Managed Long-Term Services and Supports. Leveraging technology to implement a prospective Utilization Management program, at the member-level, is a critical initiative to help achieve improved per capita service cost while maintaining positive health outcomes.
When it comes to home care, there is no shortage of assessments that capture a member's needs. These assessments can come in a variety of forms (e.g., eligibility screens, level of care assessments, uniform comprehensive assessments, functional tasking assessments, etc.) It's high stakes for Managed Care Organizations and HCBS providers to complete accurate assessments in order to equitably identify member needs, improve health outcomes, and maintain financial viability in an industry with narrow margins. Let's explore some of the reasons for errors and options to improve accuracy:
Common causes of error
The process of assessing an MLTSS member is complex and requires sound professional nursing judgement. However, there are several challenges in the implementation of assessment systems that make a nurse's job harder:
Ways to improve accuracy
Our clients use our products to apply review logic to each assessment in a matter of seconds which would otherwise require manual effort that is prone to error. This helps plans and providers achieve the aim of a comprehensive assessment system: to consistently and accurately assess members so that appropriate individualized care can be provided.