Dr Susan Mani: How to Ensure Scalability, Sustainability of SDOH Initiatives

One of the first things you need to do to ensure scalability and sustainability of social determinants of health initiatives is to really understand your population, explained Susan Mani, MD, vice president of Clinical Transformation and Ambulatory Quality at LifeBridge Health.

What are best practices for ensuring scalability and sustainability of social determinants of health initiatives?
I think one of the first things you really want to do is to understand your populations. It’s very easy to have what I call a jello on the wall approach, which you can just throw a lot of different initiatives based on what you read in a recent article, based on what you head from your best friend or another health system, but if you don’t know your population or what your population needs from looking at the data, then it’s very easy to go down this rabbit hole and to be able to scale. You could have 25 programs and still not be able to get to the outcomes that you need. I think that takes a certain amount of rigor and really spending time being strategic before you immediately start to operationalize.

Once you do that, then you can really start to hone in on what are the specific resources that you need by looking at your programs on a daily basis. By looking at process metrics, we really can tell where is the intensity of touch really needed, who is the number of the team that we really need to make sure that we have scalability on. For some of our patients, we’re finding it for their clinical needs. We really want to make sure we have the capacity for our nurses. For others where it really has to do with psychosocial needs, we really want to make sure that our social workers and our community health workers have that type of capacity, and depending on our zip code, depending on which patient population we’re looking at, those will be very different. Based on that, then you can start to scale. Start with a small population. We do pilots all the time. Based on that, we look and process and outcome metrics very robustly for all of our pilots. After 90 days, if we really are not getting to where we need, then we have to step back and say is this program the right program? Do we just need to tweak operationally, or do we really have to think about something differently?
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