Thursday, December 19 | Thought Leadership, Care Coordination, EHR Solutions and Operations

Improving Health and Quality of Life Through Social Determinants of Health and Care Coordination

By Julie Hiett, Director of Population Health Management

Netsmart Senior Director of Population Health Management, Julie Hiett, recaps a recent webinar where she and Diana Salvador, PSYD, vice president of program evaluation grants and outcomes at CPC Behavioral Healthcare (CPC), discuss how communities can improve consumer health and quality of life through Social Determinants of Health, data sharing and care coordination. 
There are a lot of buzz words in healthcare today, such as Social Determinants of Health (SDoH), population health management and care coordination. What does it all mean to you and your organization? Why does it matter and how can technology play a role? Improving how we use data to identify target populations to provide the right care is critical to the quality of health outcomes, financial risk as well as patient engagement and retention. We know social, economic and environmental factors determine 50% of overall health (Kaiser, County Health Rankings).
Individuals who are less actively involved in their own healthcare have 8-21% higher costs than those who are more actively involved and are nearly twice as likely to be readmitted within 30 days (MGMA).
Combining medical care, behavioral healthcare and SDoH data can significantly improve care, lower cost and improve quality of life for millions.
In a recent webinar, Managing Chronic Illness and Addressing Social Determinants of Health, Diana Salvador, PSYD, vice president of program evaluation grants and outcomes at CPC, and I discussed not only the ways SDoH consistently affect people’s physical and mental well-being, but also the ways organizations can leverage this data to improve care delivery and better serve complex populations. 
Let’s look at Sam. Sam is a 33-year-old male who recently started services at a Community Mental Health Center (CMHC). After completing Sam’s intake, the provider knows he has a history of severe depression and schizophrenia. He discloses he smokes and has diabetes. However, Sam can’t remember what medication he is taking or how often he has been hospitalized in the past year. He knows it is “a lot” and that one of his pills makes him really sleepy and makes him feel “out of it.” While at the health center, a Sam is prescribed medications for schizophrenia and depression. He was also instructed to seek professional counseling weekly. In order to understand Sam’s whole health history and effectively and efficiently serve his needs, his provider needs to have total access to his prescribed medications, how many hospitalizations he’s had and a history of Sam’s providers. Having a complete and up-to-date health record empowers providers to make better informed care decisions and keep Sam in the appropriate level of care. 
It’s vital for organizations to utilize a population health management platform that provides real-time data to identify who is most at risk and if there are any gaps in care. If your payors are requiring specific outcomes, you need a way to pull in that data, analyze it and prove the interventions you are providing are meeting those measures.  
If Sam is going to the hospital several times and is prescribed medications and his provider is not aware of this, this can have a negative impact on Sam’s care. If we don’t know that Sam is homeless, unemployed, cannot afford his medication or does not feel safe, he will not be able to fill the medication or properly manage his care. Therefore, his care will be negatively impacted. Regardless of how good the potential care services are, Sam’s health will not improve and could even worsen due to the SDoH influencing his response to the care plan. Another care path or additional support could have been allotted to Sam had the provider known about his unemployment and financial shortcoming. 
There are many research studies focused on protocols for diabetes and schizophrenia, however there is very little in the research focused on someone who has both and how best to manage.  In order to target and treat a high-risk population, CPC founded the Living Well with Diabetes program, specifically designed for individuals with both a serious mental illness (SMI) and type 2 diabetes. In addition to psychological treatment and peer support, Living Well with Diabetes addresses SDoH that were preventing participants from getting proper care. For example, 50% of their participants did not have access to a blood glucose kit, which is vital to managing diabetes. CPC also found 50% of participants did not have a doctor who specializes in diabetes.  By identifying these social determinants, they are able to not only provide participants what they need, but also educate them on how to manage their own care more effectively. 
“By identifying the challenges preventing them from managing their diabetes, we can use it as a roadmap to eliminate SDOH-related obstacles and make sure they are resolved,” Salvador said. 
CPC is collecting data from SMI and diabetes and using that data in unison with SDoH to enhance care and empower the individual to better manage care on their own. If the provider doesn’t know what outside conditions are affecting someone’s lifestyle, their ability to adequately and effectively treat the individual is limited. Service providers need to leverage information regarding SDoH in order to make better care decisions and improve whole person care.
Watch the full webinar to learn more about CPC’s programs, how to manage chronic illnesses in relation to SDoH, as well as how technology can help you leverage data and move toward whole-person care. 



Meet the Author

Julie Hiett Blog Photo
Julie Hiett · Director of Population Health Management

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