Help close the health equity gap using social determinants of health
Health inequities, or “systematic differences in the health status of different population groups” extend beyond factors such as ZIP code, gender, or ethnicity. Health inequities should be looked at and treated like chronic medical conditions. Since successful long-term management of chronic health conditions starts with a solid interdisciplinary team, extensive knowledge on the problem being solved, and better coordination of care, this same process can be applied to help close the gap on health equity.
One of the most impactful actions one can take is to capture information on an individual’s social determinants of health (SDOH) and use that data to make educated recommendations and decisions about a person’s care. To do this, providers must prioritize not only traditional clinical solutions and community referrals, but also focus on broader partnerships with community stakeholders.
Tips for capturing and using SDOH data
- Practice smart screening – Clinical staff should be trained on how to maintain a safe environment so that the person feels comfortable disclosing sensitive data. They should use assessment tools that have skip-logic and clinical decision support that triggers interventions based on responses.
- Document your data – Collect SDOH data using screening tools and including ICD-10 Z codes within your patient’s record. With any payment model, it is important to always document any SDOH data you collect, as it can be an important predictor in clinical care and directly impact health outcomes and performance.
- Implement a collaborative and targeted approach – Work with established community programs to share data across care settings and reduce the chances of alienating those programs or wasting resources on duplicated efforts. The data shared can aid with risk prediction and can subsequently inform caregivers with proactive interventions.
We will never close the health equity gap without a distinct focus on SDOH. Thoughtful collection of SDOH data, appropriately documented data, and a targeted approach to community work, will be required to realize whole person centered, equitable, and accountable care.
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