J01 – Lessons Learned when Using Social Determinants of Health Data

Summary

Social Determinants of Health (SDOH) are estimated to account for up to 60-70% of health outcomes, but SDOH data is often not included in health records, and is often not documented in ways that are easy for providers to use. Southcentral Foundation, an Alaska Native customer-owned healthcare system responsible for providing healthcare and related services to approximately 65,000 Alaska Native and American Indian people in southern Alaska, has used community stakeholder feedback to develop a system for handling SDOH data that emphasizes value and priority to patients, providers, administrators, and other stakeholders. The system identifies pre-existing SDOH data in electronic health records to identify SDOH needs, improve the delivery of healthcare, and inform policy decisions related to population health. To create the system, SCF conducted a review of over 100 existing screeners, forms, and service applications already in use to identify existing SDOH data collection. Once SDOH data were identified, their relative value was assessed based on criteria such as completeness (how many patients have a given data point), timeliness (data update frequency), quality (perception of accuracy), usefulness (how will it be used), and acceptability (alignment with patient needs, priorities, and concerns). These SDOH variables were made accessible along with other data, allowing users to examine the role of SDOH in healthcare at multiple levels from the individual to the aggregate. Once the system was in place, SCF worked to augment action lists with SDOH data, beginning with a nurse home visiting program for families from pregnancy until the child is two years old, incorporating the SDOH variables into an actionable format. The resulting action list let nurses and case managers more easily track the provision of care including required screeners. The action list format was so successful that it has been replicated with the Child and Family Developmental Services clinic.