Sharing SDOH Data to Improve Outcomes
In an April webinar, the Data for Better Health® team at AHIMA was joined by leaders of CRISP Shared Services (a nonprofit that focuses on sharing technology and strategies to connect clinical and social data to improve care) to discuss their experiences sharing social determinants of health (SDOH) data with community-based organizations (CBOs).
Nearly eight in 10 healthcare organizations collect SDOH data but still face challenges related to the collection, coding, and use of this clinically relevant data, according to a AHIMA survey of health information (HI) professionals in 2023. That’s an important indicator and demonstrates there is a growing understanding of the value of SDOH information across health care settings, the survey stated. The complex nature of the collection, coding, use, and exchange of SDOH data requires coordination across the health and social services sectors, the survey concluded.
Of course, as with any technology platform, understanding end user needs is crucial to building an effective tool; in this case, understanding the ways SDOH data is currently used can help to specify the necessary features of an SDOH data sharing technology platform. By mapping the process itself and considering how the data was actually being leveraged at each step, CRISP Shared Services was able to visualize how to develop a new technology to meet the need.
During the data collection process, whether on paper or a digital platform, patients are first screened for SDOH data by the healthcare provider and then referred to a CBO. After additional screening for SDOH information, the CBO will then assess the data and conclude the process by delivering their social service to the patient or referring them elsewhere.
Examples of Collecting SDOH Data
The AHIMA survey provides an example of how UCLA Health collects SDOH data to enhance patient care. UCLA Health piloted a variety of data collection and outreach programs devoted to individuals with serious medical conditions and underserved communities. It captures SDOH data on critical factors such as socioeconomic status, food insecurity, education, and language. As part of the screening, patients can fill out related information in the patient portal before their appointment. The data is reviewed by the population health team to help care teams connect patients to social services organizations that aid with housing, economic security, and other needs, the survey stated.
At CRISP Shared Services’ Maryland FASST program, patients who have been positively screened for food insecurity and recently discharged from the hospital are referred to local programs such as the Maryland Food Bank. The food bank screens the patient data again to assess the patient’s needs, sometimes resulting in referring to another CBO based on the patient needs and services the CBO can provide. If the Maryland Food Bank services fit the needs of the patient, they enroll them in their program and help provide services that tackle the patient’s food insecurity needs.
CRISP DC, which is under the CRISP Shared Services umbrella, serves as the District Designated Health Information Exchange (HIE) for the Washington, DC area. CRISP DC has evolved in recent years using stakeholder feedback to better their user experience with sharing SDOH data. Stakeholders shared that they would like to have their data all in one location and have insight into their closed loop referrals.
This led CRISP DC to develop a social needs suite within their platform. The social needs suite allows providers to see referrals, screening data, and Z codes next to the traditional clinical data that they’ve always seen during care visits. The nonprofit then developed additional tools within its system for referrals, screeners, and community resources. The social needs suite and additional tools have helped streamline the referral process and addressed the needs of their stakeholders.
Guidance for HI Professionals
The April webinar was the quarterly Data for Better Health Data Break. The discussion is available online on demand for HI professionals and others to gain insights in sharing SDOH data to improve outcomes.
Among the key takeaways from the webinar and sharing SDOH data:
- Identifying how SDOH data is used within the referral process is key to developing technology and tools to share SDOH data between healthcare entities and CBOs.
- Building trust between healthcare entities and CBOs starts with efficient data sharing technology.
- Developing a social needs suite within a platform, including referral, screening, and community resource tools, addresses stakeholder needs.
- While programs may vary in different areas, they should all address the needs of patients and providers to better deliver whole-person care.
AHIMA launched Data for Better Health to increase awareness of how collecting, using, and sharing SDOH data can improve individual and community health outcomes. The webinar and other resources from AHIMA are available on the Data for Better Health website.
Through this initiative, AHIMA is creating tools, resources, and education to support a better understanding of the importance of SDOH data and how it can be used to improve health and healthcare outcomes.
Sarah Gericke is a Program Specialist at AHIMA.