What providers say are the biggest challenges of tracking social risk factors in patients

Last month, the Physicians Foundation put out recommendations to address social determinants of health in patients.

Apart from acknowledging that social and structural drivers determine 70% of health outcomes, the Foundation highlighted the burden physicians face when tracking them

"Our healthcare system is increasingly recognizing that we cannot improve health outcomes or reduce health care costs without addressing social determinants of health," Gary Price, M.D., president of the foundation, said in a press release. “It is of utmost importance that we continue creating awareness around how social determinants of health impact our health care system and advocate for these important recommendations to improve health outcomes for all people."

Getting the data

Existing structures have not made it easy for providers to track social determinants, said Karen L. Smith, M.D., a family medicine physician in North Carolina and her county’s health department medical director. Doing so has not been built into the workflow.

It takes time to build trust with patients, to learn about them and what affects their ability to get care, from housing insecurity to lack of transport. 

The data also do not tend to live within the electronic health record, but rather in siloed databases or social service systems, said Lynda Rowe, senior advisor for value-based markets at InterSystems and a board member of a federally qualified health center. Different physicians might take notes differently, too, and then natural language processing is needed to extract and standardize that data.

Without standards to help providers capture this information, patients might miss appointments and wind up in the emergency room, Rowe explained.

She referenced the work of the Gravity Proiect, an initiative that launched in 2019 and has more than 800 members working to consolidate social risk factor data so it’s interoperable. Similarly, InterSystems aims to standardize data for providers. Offering a private health information exchange system, InterSystems aggregates and normalizes data across various health systems, making it accessible to providers and mergeable with other data to study trends. 

“It’s all about the health disparities and the health equity, and how do you balance that? Well, it’s really hard to balance that out if you don’t have the data to do that,” Rowe said.

In practice 

Under its United Against Racism initiative, Mass General Brigham is working to expand its screening for social determinants. To do so meant stacking its workforce with community health workers and digital access coordinators. 

“If we are screening we have to be able to match a positive endorsement of a social determinant with the resources and support that a patient might need,” said Elsie Taveras, the system's first chief community health equity officer. For instance, a diabetic patient could be referred to a food pantry if they are food insecure. 

The next step was practicing social risk-informed care. Clinics were given tablets with screening questionnaires for patients to fill out upon their arrival. If there is a positive endorsement for a social risk factor, a community health worker follows up with the patient on it, and for those not digitally literate, so does a digital access coordinator.

Mass General Brigham also matches patients with a chronic condition to digital health resources by supplying them with take-home tablets that they can use to connect with their provider virtually outside of in-person visits. That care is managed in part by bilingual digital access coordinators.

Last year, the system launched mobile services for people who could not come in person. In total, four mobile vans have gone into 20 different communities with over 70 community partners, Taveras said. She stressed the importance of considering maximum impact and how to “get out of brick and mortar, getting boots on the ground, in the communities that we serve.” 

The importance of reimbursement

When physicians notice the impact of social determinants but lack the tools to make a meaningful difference, burnout accelerates. Part of that means being compensated for the work, and why it’s critical to incorporate social determinants into payment models.

Tracking social determinants is much more than merely tracking data; it means actively engaging in the community. To address the exacerbated opioid crisis in her community during COVID-19, Smith’s health department met with the sheriff, the state attorney, patients and the school system to brainstorm ways to fight.

“Now we’re finding the importance of coming together,” Smith said. “Share with me so that I can walk in your shoes for just a few minutes.” 

The problem with the fee-for-service payment model, Smith explained, is that it doesn’t allow for continuity of care. A physician might be paid for a visit, but beyond that, they are not paid to ensure the patient can get to a pharmacy or even communicate while there. The blended payment model is a step above that, she noted, but the ultimate goal should be a comprehensive payment model that allows for a physician to engage with the entirety of a patient’s care journey. 

“Is there a way in which we can rise it up and go upstream so they have the opportunity to have good health beyond healthcare delivery?” Smith said.

The Center for Medicare and Medicaid Innovation (CMMI) is now offering what Rowe called global payment -- paying providers a bulk sum they can distribute at their discretion to address things like social determinants. That helps recognize that there is more than one part to the health system and that there should be a model that does not penalize providers for delivering that care, Rowe said.

RELATED: CMMI director: Expect more mandatory value-based care payment models

One example of CMMI’s effort is its Accountable Health Communities model that connects public payer beneficiaries with community services. But, the Foundation pointed out in a report on the topic, CMS Medicare Shared Savings ACO quality measures do not include social conditions.

Taveras acknowledged that while implementing these solutions at scale reduces preventable hospitalizations, doing so requires leadership, institutional commitment and resources. Providers must decide whether that’s an investment they’re willing to make, though the return on it is evident. But even with the support, Mass General Brigham struggled under the widespread labor shortage.

“It has been incredibly challenging to fill all of the roles that we are looking to fill,” Taveras admitted.