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Successful Interventions, Positive Outcomes: Understanding the Impact of Social Determinants of Health
January 30, 2018

Successful Interventions, Positive Outcomes: Understanding the Impact of Social Determinants of Health

Medecision is a leading provider of population health management technology and services for risk-bearing healthcare organizations across the care continuum. Why? 25-plus years of insight, innovation, and proven implementation. Health plans, hospitals, and health systems rely on Medecision and its Aerial platform and applications for a more effective path toward effectively managing new populations and confidently managing through market changes and regulatory updates, while improving quality and reducing costs. It’s not enough to deliver technology. Medecision is driven to create real solutions that solve real problems, with the goal of improving the care and outcomes of everyone involved.
No program will be perfect at first, either. As an industry, we’re all relatively new to the concept of managing social determinants of health for member populations. That is why it’s important to create a framework that encourages ongoing evolution. Focus on:
  • Achieving enterprise alignment
  • Harnessing the power of data to identify meaningful opportunities for clinical and financial improvement
  • Leveraging technology to intervene and engage members
  • Continually measuring and improving performance

For the greatest initial impact, start addressing social determinants of health for populations at highest risk, such as those with dual eligibility. One “success story” that illustrates the effectiveness of a home-based community health model for dual-eligible populations is the Health Connections Initiative launched by Catholic Health Initiatives. 

This program combatted health disparities in 3 different parts of the country. Health Connections team members lived and worked in the communities they served, which helped boost participant acceptance. Team members identified participants for interventions who: lived in poverty (socioeconomic status); lived in geographic locations known to lack community support resources (geographic status); and had one or more health conditions requiring medical treatment (disabilities).

Community Solutions
Programs such as the Health Connections Initiative recognize that the key to mastering social determinants of health is to build community collaborations that span the entire care continuum. Whether health plans want to pursue bundled payment programs or specific population health initiatives, they must identify the social determinants that impact the population being served, then design a care model that addresses those disparities at the right place in the care continuum.

Let’s say a member has just been discharged after a total knee replacement. You can hardly expect her to go to physical therapy 3 times each week if her only transportation is a city bus that she cannot board with her walker. Ultimately, the intervention can only be successful if a community team works together to resolve her transportation need.

Addressing social determinants of health to improve population health is all about working with provider teams to solve these types of problems. Technology can play an important role connecting the entire care community in real time. Applications like Aerial InCircle, for example, can unite plans, provider teams, members and others to enable a continuum-wide and collaborative approach. Such secure social networking tools make it easier and faster for members to communicate with care teams and engage their support networks of family and friends. In one program, women with gestational diabetes found it a simple way to report their blood glucose levels, get their questions answered quickly, and enlist the right support when needed.

There is no single solution for overcoming the many, complex disparities that exist in healthcare. What we can do, however, is enable community collaboration and encourage ongoing alignment and improvement. We can start to chip away at social determinants of health, building strong community support networks that give everyone a chance to achieve health and wellness.
 

 
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