In terms of population health management, can we use the data to find common SDoH issues that impact many patients, and find best practices to counter? One example is data from HHS’ Agency for Health Research and Quality, which found as far back as 2013 that malnutrition is a factor in 12 percent of non-maternal, non-neonatal hospital stays, accounting for $42 billion in annual healthcare spending. Is it avoidable, and how can a primary care team bridge community services to avoid these hospitalizations and costs?
A Chicago-based ACO much more recently began screening high-risk patients for malnutrition, and offering post-discharge follow ups such as community referrals and nutrition coupons. The ACO reports savings of more than $3,800 per patient.
But can acting on SDoH data really become a part of universal workflows and even be a factor in healthcare business models?
Medicare Advantage plans, beginning in 2020, are developing some inroads by way of reimbursement fees for transportation, food and levels of in-home support for chronically ill patients. That’s a big step, in line with last year’s policy goals statement by HHS that broad SDoH payment models are being looked at.
These points of tangibility can take social determinants out of the abstract as just another data point and advance case management to the community level, and at the same time hopefully derail the notion that SDoH only impacts Medicaid-level or poor patients. We all have habits and markers.
What’s even more encouraging big picture is a January, 2019 report in the peer journal Academic Medicine that published a consensus call to build clinical approaches to social determinants into medical school curriculums.
Thoughtful but impactful steps can mean a lot to patients and providers struggling to find common ground.
1 Schroeder, M.D., Steven A., We Can Do Better – Improving the Health of American People. NEJM, 2007, Sept. 20: 357;12 1221-1228.