Features highlights from a presentation at the Illinois Association of Medicaid Health Plans conference

Health plans play a critical role in ensuring access to healthcare, delivering high-quality care and helping patients achieve optimal outcomes. As a result, they are increasing their capacity beyond traditional strategies and diving deeper into community data to help them understand the barriers to good health among their members.

This is a quick snapshot of three strategies to jumpstart your work, understand barriers to achieving better health and give you actionable insights as you consider how to incorporate social determinants of health (SDOH) into your decision-making process.

Equity in every assessment

We know that minority communities have suffered from disinvestment and a lack of adequate resources for a long time – and not just healthcare resources. Using basic demographics, you can embrace and acknowledge the diversity of populations, racial and ethnic backgrounds, languages and abilities. You should also understand how your members compare to the community at large.

Do your members reflect the community demographics? Are there opportunities to change disease trajectory in membership through SDOH interventions? What are the barriers that impact either severity or progression of a disease? How do SDOH contribute to progression of specific diseases? Grounding your understanding in the community, rather than just the slice of members you serve opens up immediate insights and opportunities to think differently.

There isn’t just one question

When we talk about the social determinants of health, we are talking about the fabric of our lives. You can’t just pull one string and fix everything. Let’s take housing stability as an example.

National Institutes for Health (NIH) research declared that “facilitating eligibility for scarce and dwindling low-income housing were key to stabilizing patients’ health and life conditions.” And addressing that before someone became homeless was key to better outcomes.

It is hard to “see” housing instability from the outside. There are so many variables that impact individuals in different ways. However, there are signs like – having trouble paying rent, overcrowding, poor housing conditions, moving frequently or spending the bulk of household income on housing. These experiences may negatively affect physical health and make it harder to access health care. For instance, take a look at these benchmarks.

Housing Instability – Metopio

Mix and match resources that are available

There are so many issues at play here, it can be overwhelming to get a complete picture of an individual without community context but where do you start?  There are an endless supply of screening questions, indices and tools you can use to identify what social determinants of health might be driving a patient’s outcomes.

Complete screening for every factor is overwhelming to the patient as well as the provider or individual charged with delving into how an individual lives and experiences their community. One way to take a step forward and find cumulative impact is to assess what patient outcomes you are trying to improve and match them to the resources you have available.  Aligning these two can produce some measurable outcomes in the near term and provide you with indicators that will help you scale effective interventions with less risk and a higher likelihood of success.

For example, if there is a successful food delivery intervention for nutrition for at-risk pregnant mothers you could screen for barriers to eating healthy such as limited time and resources to purchase and prepare healthy foods. Constructing a screening which focuses on these barriers could include usual hours worked, access to childcare, single-parent households, living in a food desert, access to transportation to name a few. This way you a) have an intervention you can match to the need such as connection to social programs such as SNAP, WIC or even the possibility of grocery delivery, and b) you are able to close the gap and measure success before tackling the next challenge.

Combining community data with the insights you have on your members at a population level is a quick way to jumpstart your analysis and find opportunities to improve health outcomes.

Metopio can provide data to your teams

At Metopio, we work to make data accessible and useful to anyone regardless of their data science background. This empowers changemakers across your organization to incorporate vital community data into their decision-making process. Our intuitive data tools make it easy to visualize and understand information across economic, demographic, environmental, social, and healthcare outcome and utilization metrics.

To learn more about these insights and get started, contact us at angie@metop.io.