i2i Insights: Social Determinants of Health Can’t Be Ignored

Based on a meta-analysis of nearly 50 studies, researchers found that social factors, including education, racial disparities, social support, and poverty accounted for more than a third of total deaths in the United States in a year.

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Janice Nicholson

Article by Janice Nicholson, Co-Founder

A hot topic, Social Determinants of Health (SDH) are not generally deployed into Population Health Management platforms (PHM)—not yet anyway. However, there is a great deal of chatter about it.

We’re thrilled to hear the conversation on social determinants, which inform the conditions in which people are born, grow, live, work, and age. In fact, in a recent webinar i2i shared some tremendous feedback from industry veterans working in the trenches who are actively leveraging SDH to make a difference.

It has long been known that health outcomes are substantially influenced (for better or for worse) by environmental and behavioral factors including economic stability, education, the physical environment, and access to healthy food.

And it is likely better understood that genetic factors are strongly linked to inheritable diseases, for example, patients with the BRCA1 gene mutation experience a higher risk of developing breast and ovarian cancers.

Although both environment and behavior are relevant, data science has validated that social determinants are equally—if not more—influential in terms of impacting health outcomes.

For several years i2iTracks has tapped into geographic and demographic data to create a more robust PHM experience for both providers and patients. And more importantly we’ve validated that it really makes a difference in developing a successful PHM strategy.

How i2i Incorporates SDH into Real Care Coordination

Behind the scenes, i2i adds SDH data into daily huddle reports. Providers and case managers, for example, can easily access important information such as the patient’s homeless status or prior incidences of domestic violence. Clinicians can then take these into account as they prepare for the visit and also act accordingly when following up on missed visits.

Social Determinants Are a Two-Way Street

We hear a lot about how social determinants of health impact and influence a patient’s health. But the real focus is on how the healthcare system can impact and influence those social determinants as well, to create a more positive feedback loop.

Here’s how that might work in practice. A nurse practitioner might identify a group of patients who live in economically deprived zip codes and know that they likely have a greater propensity for smoking and poor nutrition. Instead of just treating the symptoms and diseases associated with those risk factors, the healthcare system can proactively engage the patient to offer smoking cessation education and access to nutritionists.

The i2i Advantage

What’s interesting is that some PHM vendors are just now investigating how they might be able to integrate SDH factors into their systems, but i2i Tracks has already harnessed the power of social determinant data, and clients around the nation are using this feature to improve health outcomes for patients.

It’s exciting to be at the forefront of the revolution in PHM, with the introduction of more data. In terms of how the industry will evolve to leverage the deep insights related to this information, the possibilities are truly endless.

We’re eager to help even more providers apply these insights.

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