Introduction
Incorporating social determinants of health (SDoH) into care is critical yet complex for medical directors and quality managers. Integrating SDoH data drives quality improvement, aligns with managed care goals, and fosters patient trust and engagement. Today, we’ll explore actionable strategies that ensure SDoH data directly impacts quality metrics, care planning, and patient outcomes.
Addressing SDoH to Improve Quality Metrics in Primary Care
Addressing SDoH effectively goes beyond improving individual patient outcomes; it directly influences core quality metrics, especially for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).
Creating Patient-Centered Quality Metrics with SDoH in Mind: Traditional quality metrics may overlook patient context, which can skew data and mask opportunities for improvement. Clinicians can develop interventions that impact real-world outcomes by designing metrics that account for SDoH data (such as tracking the percentage of patients who screen positive for food insecurity). For example, a metric around housing stability might prompt the clinic to develop partnerships with local housing support services, which can, in turn, reduce ER visits related to chronic health issues aggravated by housing conditions.
Aligning SDoH Initiatives with Managed Care Goals: Many managed care goals emphasize cost reduction, outcome improvement, and patient satisfaction, all influenced by SDoH. For example, readmission rates often correlate with unmet social needs. Tracking metrics that consider SDoH can thus reduce readmissions and improve managed care performance.
Trade Secret Tip: Try piloting a new SDoH-informed quality metric each quarter and compare outcomes with the previous year. This will allow you to see the direct impact of addressing SDoH on core quality measures, helping to fine-tune your initiatives.
Embedding SDoH into Patient Care Plans and Clinical Workflows
Incorporating SDoH data into care plans transforms standard patient interactions into personalized care experiences, addressing factors that might otherwise be overlooked.
Using SDoH-Integrated EHR Systems to Inform Treatment Plans: Embedding SDoH fields in your EHRs ensures that clinicians see the full picture when assessing a patient’s needs. For example, when a patient’s record notes transportation difficulties, care plans can include virtual follow-ups or home-delivered medications. This tailored approach ensures adherence to treatment, benefiting both patients and quality metrics.
Create Individualized Treatment Pathways: Standardizing SDoH as part of care pathways allows clinics to develop individualized interventions. For instance, patients with financial instability may be directed to cost-effective treatment options or given resources for financial support. This personal touch improves patient outcomes and builds loyalty, as patients feel their care reflects real-life situations.
Engagement Insight: To guide care discussions, clinicians should review SDoH fields before patient intake. When patients see that providers understand their life challenges, trust and adherence improve, leading to better outcomes.
Leveraging SDoH Data for Quality Improvement Initiatives in FQHCs and RHCs
Data-driven quality improvement (QI) initiatives incorporating SDoH data can lead to impactful, targeted changes in care delivery.
Designing Data-Driven QI Projects Around SDOH Themes: When SDoH data reveals trends in unmet needs, such as food insecurity, QI initiatives can target these areas specifically. A clinic seeing high food insecurity rates might partner with local food banks, creating a reliable referral pathway that ensures patients have access to nutritious food—directly impacting health and reducing future healthcare needs.
Creating and Sustaining Community Partnerships: Partnering with community organizations, such as housing agencies, financial support groups, or transportation services, strengthens a clinic’s ability to address SDoH. These partnerships extend beyond the clinic walls, offering patients comprehensive support and reinforcing quality initiatives through shared resources.
Trade Secret Tip: Establish “warm handoffs” to community partners. When staff can personally connect patients to resources rather than just providing information, patient follow-through and satisfaction rise—impacting quality metrics and health outcomes.
Engaging Support Staff to Connect Patients with Resources
Support staff are essential in helping patients navigate available resources. Their direct, trusted interactions with patients position them perfectly to make meaningful connections to SDoH resources.
Training Support Staff to Identify SDoH Needs Efficiently: Empower support staff with quick, straightforward training on SDoH assessment tools. This way, they’re screening for social needs and equipped to offer immediate support, such as connecting patients to resources or sharing information.
Resource Guides for Frontline Staff: Providing an easy-to-access digital directory of local resources, from food banks to transportation assistance, ensures staff can quickly connect patients with services. Many clinics find printed resource cards or quick-access lists within EHRs to help frontline staff make efficient referrals.
Engagement Insight: Keep your staff motivated by showing how their efforts impact patient outcomes and clinic quality scores. Job satisfaction and performance increase when they know their role is valuable to patients.
Integrating SDoH data into primary care can significantly boost quality metrics and help achieve managed care objectives. Medical directors and quality managers can make a powerful difference in patient outcomes by focusing on tailored care, data-driven initiatives, and community partnerships.
At BCA, we offer auditing and consulting services to support your practice in maintaining compliance and enhancing the quality of care. Documentation review starts at $499 per clinician. Contact us at info@bcarev.com to learn more about our tailored solutions and how we can help you optimize your quality initiatives.