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To tackle social determinants is to disrupt the underlying causes of and contributors to poor health. Research shows that addressing even a small number of modifiable risk factors, such as tobacco use and poor diet, can have a large effect on mortality reduction and disease burden.
But there is no "silver bullet" data source that paints a full picture of social needs, and patient self-reporting of social determinants results in only a limited set of insights. In many cases, it’s the absence or unproductiveness of these patient conversations that creates the first barrier to addressing social determinants: Too many patients walk out of physician offices with prescriptions they can’t afford, follow-up appointments they can’t get to, and advice they will have a hard time following. Unless clinicians know specifically what to ask about, they may not get an actionable answer as to whether a patient needs help, and what sort.
But if we use social determinant data to inform our backstories on these patients, then validate and continue to fill in the blanks on each individual, then we can better tailor care and activate community resources to address care needs.
"By arming advisors with holistic social determinants of health information, we’re able to better understand a patient’s backstory and the hurdles that may be preventing them from staying healthy"
To help inform these conversations and jumpstart interventions, Evolent Health has created an index that aggregates multiple data sources into a quick, easy-to-act-on snapshot of a patient’s social determinant of health risks. The Evolent Health Social Needs Index comprises over a dozen dimensions, including income level, education level, neighborhood type, employment and economic situations in the neighborhood, personal family picture, and more. All of these variables are aggregated into a single number on a scale of 1-5, which represents the severity of the nonmedical issues at the patient level. The higher the number, the greater the likelihood that these nonmedical issues are having an impact on an individual’s health outcomes.
Ultimately, this number is designed to identify whether a patient has many issues to deal with, or one to two that are manageable. The end goal is to offer a starting point for care providers on how to best communicate with a patient about their health. By arming advisors with holistic social determinants of health information, we’re able to better understand a patient’s backstory and the hurdles that may be preventing them from staying healthy. We can ask the right initial questions—the ones that prompt answers that suggest which next steps will have a true impact and activate a targeted plan that fits the patient’s unique needs.
For example, if we know a patient is struggling with diabetes, the first conversation would evolve from, "we have an awesome new program to help with your diabetes," to "are you having any issues accessing or storing your medication that we can help you work through?" In turn, this helps us uncover the root of the problem and pinpoint the gaps a patient may have in accessing the right care or treatment. Based on this information, we can continue to validate and build on our findings over time to provide a more tailored care approach for the patient.
Physicians and care advisors already juggle an ever-growing mountain of clinical data. With a simple Social Needs Index that prompts specific questions, they are better informed to bring more human connection and relevance into their patient conversations, and to better uncover and address patient challenges that need to be factored in to the care approach.