In the vast healthcare landscape, the role of social determinants of health (SDOH) – a powerful blend of social, economic, and environmental conditions – is often overlooked. As these determinants shape population health outcomes, mitigating barriers at the intersection of SDOH and healthcare is imperative.
Illustration by Mike Werner
The words of Dr. George Bray, a renowned endocrinologist, capture this significance aptly, “Genetics loads the gun, and environment pulls the trigger.” According to the World Health Organization, an astonishing 80-90% of health outcomes can be attributed to SDOH.
Understanding the Patient Experience: The Unseen Impact of SDOH
Consider the 23 million Americans who live in food deserts, grappling daily with the challenge of accessing fresh, nutritious food. Imagine the 3.6 million Americans who delay or forgo crucial medical care due to transportation barriers. Or think of the children growing up in underserved neighborhoods, their academic performance, and lifelong health trajectories influenced by circumstances beyond their control. These scenarios vividly show how SDOH can significantly impact patient experiences and health outcomes.
Taking Action: Steps towards Managing SDOH and Care Barriers
Addressing SDOH and managing care barriers requires a robust and actionable strategy. Zyter|TruCare offers a comprehensive framework, focusing on the interplay of Goals and Interventions, which is critical for successful care programs. Healthcare organizations should take the following actions to provide more personalized, holistic care for better outcomes:
- Integrate Holistic Health Profiles: Comprehensive health profiles are crucial in disease prevention, early detection of health issues, and promoting healthier lifestyles. Assemble a comprehensive patient health profile by gathering and analyzing data from various sources. These include clinical, social, environmental, financial, and educational factors.
- Identify Care Gaps and Goals: Use the comprehensive health profile to identify gaps in care and align them with the individual’s care goals. This alignment considers an individual’s social models of health and other factors, including their insurer’s clinical care policies. By identifying gaps in an individual’s health, healthcare professionals can create personalized care plans that address specific needs and prioritize interventions.
- Design and Implement Effective Interventions: Designing and implementing effective interventions in value-based healthcare requires a thoughtful and data-driven approach focusing on improving patient outcomes while optimizing costs. Data-driven insights are essential for identifying areas that need improvement and measuring the impact of interventions. Collect and analyze relevant data, including clinical outcomes, cost patterns, and patient utilization at every touchpoint in the care continuum.
- Deploy Advanced Technology: Leverage artificial intelligence and machine learning to interpret aggregated data and generate actionable recommendations. This technological integration aids in resource optimization, patient engagement enhancement, and proactive patient care promotion.
- Personalize Solutions for SDOH: Go beyond just treating clinical conditions. Address specific social determinants and care barriers, tailoring solutions to each patient’s unique SDOH challenges. Operationalize data analytics, partnerships, and targeted interventions. Providers and care managers should work with individuals to fully understand their challenges and connect them with appropriate resources and community-based organizations.
- Collaborate with Community-Based Organizations (CBOs): Form partnerships with CBOs, social service agencies, and local nonprofits. These organizations can provide educational or related services based on the individual’s unique needs, such as helping people find food and employment, pay bills, and secure a place to live. Strong partnerships can help healthcare organizations to extend their reach and offer a broader range of social support services. Keep track of these referrals to maintain a holistic view of patient care.
As Sir William Osler, the “Father of Modern Medicine,” aptly put it, “The good physician treats the disease; the great physician treats the patient who has the disease.” This reality underscores the importance of SDOH management in healthcare.
Revolutionizing Care Management and Empowering Long-Term Support with Zyter|TruCare
In our quest to revolutionize care management, Zyter|TruCare offers a comprehensive suite of solutions, each designed to impact patient outcomes and informed decision-making profoundly. From targeted interventions for chronic diseases and medication therapy to promoting wellness and breaking barriers to social determinants of health (SDOH), our solutions empower individuals to take an active role in their care.
With a firm belief in the significance of addressing SDOH, we recognize that achieving value-based care, improving health outcomes, building patient trust, and promoting health equity depend on this crucial aspect. As Helen Keller once said, “Alone, we can do so little; together, we can do so much.” We can transform modern healthcare into a more equitable and patient-centric system through collaboration and addressing the social, economic, and environmental conditions.
As a testament to our commitment to comprehensive care, we have introduced TruCare® Home and Community Services ™, an add-on module that seamlessly integrates with our award-winning population health platform. This innovative solution focuses on meeting the long-term care needs of individuals with chronic health conditions or disabilities, ensuring accessibility and promoting health equity.
TruCare® Home and Community Services™ empowers care coordinators, nurses, and agency providers with a workflow-driven, configurable, Long-term Support and Services system. Engaging with patients throughout their health journey enables them to maintain independence and enhance their quality of life. The solution efficiently facilitates the coordination of Medicaid and Medicare waiver programs, aligning with Federal and State guidelines under Home and Community-Based Services 1915(c).
One of the key benefits of our automated workflows is that care teams can create patient-driven care plans tailored to specific state requirements, thus expediting processes and elevating participant satisfaction. This comprehensive solution includes program enrollment tracking, efficient service request management, individualized service plans, configurable assessments, automated tasks, team-based assignments, documentation generation, and integration with findhelp, America’s leading social care network.
With TruCare® Home and Community Services™, healthcare organizations can establish a seamless and streamlined system that enhances assessments, care plans, and community support identification and integrates behavioral and medical health programs. We aim to deliver compassionate, comprehensive care to empower individuals and ensure a healthier future for all.