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Using Data to Address the Most Prominent Social Determinants of Health in Your Community

Friday, October 16, 2020   (0 Comments)
Posted by: Crysta Maniscalco
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by Emily Holzman and Heather Budd of Azara Healthcare


Heather Budd from Azara will be presenting with NorthShore Health Centers at the NWRPCA/CHAMPS 2020 Virtual Fall Primary Care Conference from 1:00-2:00PT on 10/20.


The idea behind the term “social determinants of health” is not new but knowing how to use them to make a difference has always been a challenge. One of the earliest references is John Snow’s identification of the well pump that was the source of the infamous 1854 London cholera outbreak. Back then, physical addresses determined where people could access water. The Broad Street pump was in a poor, crowded neighborhood with unsanitary conditions and contaminated water1. More recently, in April 2014, the low-income city of Flint, Michigan changed its public water source to the Flint River. Corrosives in that water caused lead in the pipes to enter the supply and poison its citizens, generating a litany of short and long-term impacts on the community. Elsewhere, polluted air, food deserts, lack of nearby educational resources, and more affect our more vulnerable communities. Health centers are acutely aware that health outcomes are largely defined by social and economic factors. Addressing them is central to the community health center mission of improving health for all.


Unfortunately, their awareness does not make it obvious how to impact the problem, particularly when time and energy spent addressing these issues may not be reimbursable. Treating a patient for uncontrolled diabetes is challenging, but when you factor in other barriers like unstable housing, lack of fresh food options, and transportation challenges, the approach must change, along with diversification staff types needed to assist. Data can help inform the changes. Care team members may understand the landscape of their patient population instinctively, but how can any solution be scaled to that population without the means to track and record actions and outcomes? A single patient’s referral to a food bank or utilities coverage is a small victory; leveraging resources for an entire community struggling with similar health risks is possible with population health management, without relying solely on providers.


To make use of any population health tool, care teams must determine what to look for. Envisioning a broader solution to those challenges seems impossible when considering individual cases, so the ability to quantify the most salient conditions through data collection is the first step toward a larger scale intervention. Take for example a high no show rate among a patient population. If a group of patients is not physically showing up to the center, how can a provider discuss basic health care concerns, let alone close gaps in care? A robust data platform can identify all patients who no showed, then pick out common themes such as zip codes, poverty levels, material insecurity, childcare, etc. There will never be a single culprit for an entire community; social determinants of health are too multi-faceted and complex, but data can help identify the biggest factors. If a center uses its data to discover that many no-shows come from patients living in a transportation dead zone, then the nebulous issue of no-shows has been translated into a concrete problem with the hope of a concrete solution. A center could provide transportation and advocate for change in the community to address it in a sustainable way. Or, it might determine how to see this population remotely, by taking the clinic to the patients with mobile resources, or use technology like telehealth, to virtually connect patients to care.


The translation aspect is where data can be most powerful, converting bits of information into a bigger overall meaning, or proving out instinctive assumptions. For example, the Montana Primary Care Association, is aware its state has a large population of veterans, but that understanding is not yet reflected in community health center data. Before they can reasonably expect to galvanize wide-scale provision of services to this population, they are working to accurately quantify this group first.


The local knowledge and understanding of community health center workers are crucial in knowing where to start looking and what needs to be collected. Now their observations are especially pertinent in addressing added stressors from COVID. Data serves to illuminate and more sharply define what health care workers observe and it provides an unemotional platform on which to base steps toward change in health care delivery and to celebrate the extraordinary work health centers deliver every day.








NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

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