In recent years, the healthcare system in the United States has changed, particularly in patient management and coordination. A key factor in these changes is the increasing acknowledgment of Social Determinants of Health (SDOH) in overall patient management. SDOH refers to the conditions in which individuals are born, grow, live, work, and age. These factors have a significant impact on health outcomes, access to care, and health service use. For medical administrators, owners, and IT managers, it is essential to understand how SDOH data can improve patient management and care coordination.
As of 2021, almost all non-federal acute care hospitals (96%) and about 88% of U.S. office-based physicians had adopted some form of Electronic Health Records (EHR), showing significant growth compared to previous years. Notably, 85% of those physicians are actively recording SDOH data within these systems. The collection of this data electronically has changed how healthcare providers deliver care, giving a broader view of patient needs and barriers to health. Increased EHR adoption not only simplifies patient information management but also serves as an important tool for incorporating SDOH into clinical practice.
Fragmented care can result from poor communication among healthcare providers, often leading to conflicting treatments, repeated tests, and higher costs for patients. By utilizing SDOH data to coordinate care effectively, healthcare providers can better manage chronic conditions and enhance patient outcomes. For example, a patient facing economic challenges may find it hard to afford medication or follow-up appointments. Identifying these challenges through SDOH data enables healthcare organizations to connect patients with community resources, leading to a more comprehensive approach to care.
Effective care coordination is critical to prevent negative health outcomes tied to fragmented care. It involves organizing a patient’s care across various healthcare providers. Smooth communication between primary care physicians and specialists is vital. Administrative leaders in hospitals and medical practices must focus on improving this communication to provide better care quality.
A key aspect of care coordination occurs during follow-up care after hospital discharges. This transition can be complex and is a crucial time when coordination is necessary to prevent complications. Making medical histories, treatment plans, and SDOH data accessible to all providers involved in a patient’s care can greatly enhance outcomes. When providers effectively utilize EHRs, it allows for real-time sharing of patient information, ensuring continuity of care needed to manage chronic or acute conditions.
The practical benefits of incorporating SDOH data into healthcare practices are clear. For instance, a 70-year-old patient with heart failure may face various social factors affecting their health, such as limited transportation or difficulty accessing healthy food. By documenting these factors in EHRs, healthcare providers can develop actionable care plans that include not only medications but also referrals to relevant social services.
Providers can also monitor health outcomes and correlate them with collected SDOH data, which enables better-informed decisions that align care plans with patients’ life situations. This broad view helps healthcare administrators advocate for policy changes or more resources that meet the needs of their patient populations, promoting better health equity.
An emerging trend in healthcare is the application of Artificial Intelligence (AI) and workflow automation technologies to streamline administrative tasks and improve patient management. As healthcare providers increasingly realize the importance of SDOH data, they can use these technologies to enhance workflow efficiencies.
AI can aid in automating the collection and analysis of SDOH data. For instance, automated systems can flag cases where a patient’s reported social conditions might negatively affect their health, allowing for timely interventions. Automation also reduces the administrative workload for healthcare staff, allowing them to concentrate on patient care. For administrators and IT managers, integrating AI-driven solutions can achieve several goals: improving data accuracy, enhancing patient engagement, and strengthening care coordination.
Moreover, improved call automation systems can significantly enhance front-office operations. By automating phone responses and information gathering, practices can enhance the efficiency of patient interactions while collecting important data that can be incorporated into EHR systems. This not only improves patient satisfaction but also enriches the overall understanding of a patient’s situation, further aiding the integration of SDOH data into their care plans.
Despite the advantages of integrating SDOH data into patient management, various challenges persist. Healthcare providers often struggle to access comprehensive datasets due to privacy concerns or inconsistent data collection across different EHR systems. As of late 2021, 81% of individuals visiting healthcare providers reported gaps in information exchange, pointing to potential issues in coordinated care.
Providers need to make a concerted effort to establish unified protocols for collecting, sharing, and using SDOH data. As previously mentioned, the Centers for Medicare & Medicaid Services (CMS) have implemented requirements to standardize processes for information exchange among healthcare stakeholders. Following these guidelines can help reduce risks related to information blocking and promote a culture of collaboration.
Accountable Care Organizations (ACOs) have become important in improving care coordination among providers. These organizations consist of groups of healthcare providers who collaborate to deliver quality services and enhance health outcomes while managing costs. They motivate providers to participate in coordinated care practices, helping to align patient care objectives with broader organizational goals.
By being part of ACOs, practices can improve communication between primary care physicians and specialists, ensuring effective use of SDOH data in guiding care decisions. Additionally, ACOs promote the sharing of clinical insights and best practices among providers, creating a community focused on collective improvements in quality of care.
For medical practice administrators, owners, and IT managers, integrating SDOH data into patient management and care coordination is essential for maintaining quality care in an evolving healthcare system. As healthcare practices become more data-driven, several strategies should be considered:
By adopting these strategies, healthcare leaders can better navigate the complexities of patient management concerning social determinants. As the healthcare system continues to evolve, proactive engagement with these factors will be important for promoting better outcomes and ensuring patients receive the comprehensive care they need.
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