Navigating high risk SDoH patients to resources and strategies for improvement

Government mandates focus on identifying vulnerable patients within the healthcare system who are affected by non-medical health factors related to social determinants of health (SDoH). These mandates are triggering healthcare systems to gather and report on SDoH data in inpatient and outpatient settings. But do hospitals and state organizations have the necessary resources to fully comply with these requirements? In this blog post, we will explore the journey from identifying a patient as high risk, examine the availability of resources and discuss strategies for improvement.

The real world scenario

To illustrate the challenges and complexities of addressing SDoH, let's consider a real life scenario. A patient arrives in the emergency department (ED) due to domestic violence, housing issues and economic struggles. Her high risk needs are identified through a Health-Related Social Needs (HRSN) screening tool, and the hospital's social worker is promptly notified. The HRSN screening tool identifies Z codes related to her social needs, and resources are made available upon her discharge using this data.

But what lies ahead for this patient? The state advocate offers her options to apply for housing support. However, there's a catch – the state only offers two months of support per applicant; there is a limited budget that is allocated, and once the monthly funding is exhausted, there are no additional funds for another month. The patient faces a choice: temporary shelter with limitations for her family of three or a four-month wait for permanent housing assistance. This scenario forces us to examine the true accessibility of critical resources.

The importance of SDoH

SDoH helps shape health outcomes for individuals and communities – up to 55% of health outcomes are influenced by non-medical factors. HRSN screening tools effectively identify social risks and provide vital data on these factors. Healthcare systems must utilize this data to provide the necessary support and start to close the loop. However, when patients request assistance, but face difficulties accessing help, they may lose trust in the healthcare system, potentially discouraging them from seeking help or identifying social needs in the future. This scenario highlights challenges from data capture, resource limitations, time lags and continuity of care, and emphasizes the need for comprehensive solutions that provide accessible, immediate and sustainable support. Identifying patients affected by SDoH factors and providing them with the necessary assistance is a complex effort, further complicated by systemic hurdles and technology barriers.

Strategies for improvement

1. Standardized screening tools: Implementing standardized tools across healthcare settings ensures consistent and accurate identification of SDoH factors. 
2. Technology integration: Leveraging technology, such as electronic health records (EHRs) and HRSN screening tools, to improve the capture and utilization of SDoH data. Use this data to inform various actions, such as tracking referrals, sharing information with community outreach programs and collaborating with social organizations.
3. Community collaboration: Collaborating with community organizations to bridge resource gaps enables more efficient connections to services. 
4. Policy and advocacy: Advocate for policy changes at the state and federal levels can increase funding for SDoH initiatives, addressing resource limitations. 
5. Success stories: Highlighting successful interventions or community partnerships that have made a significant impact and have led to improved health outcomes. 
6. Patient empowerment: Empowering patients to advocate for their own needs is essential. This can be achieved by connecting patients to community resources through web-based platforms, ensuring they have the access to the support they need. By doing so, patients can be active participants in their care plans. 
7. Long-term solutions: Exploring long-term strategies for addressing SDoH, such as sustainable funding models, ongoing training for healthcare providers, and continuous improvement of data collection and reporting methods, is vital. 

Conclusion

Navigating the challenges of SDoH from identification to resource availability is a multifaceted process. Government mandates have prompted healthcare systems to identify high risk patients and gather SDoH data, but the real test lies in the availability and accessibility of assistance. The real world scenario of a patient facing domestic violence, housing issues and economic struggles highlights the complexities involved. Despite identifying her needs through an HRSN screening tool and providing initial assistance, the limitations of state support and budget constraints pose significant hurdles. This scenario underscores the importance of comprehensive solutions that ensure immediate, accessible and sustainable support.

To address these challenges, healthcare systems must implement standardized screening tools, leverage technology for better data capture and utilization, and foster community collaborations. Policy advocacy and highlighting success stories can drive systemic changes while empowering patients through web-based platforms ensures they remain active participants in their care plans. Long-term strategies, including sustainable funding models and continuous improvement of data collection methods, are essential for creating a supportive and effective healthcare environment. By adopting these strategies, we can better navigate the complexities of SDoH and work towards a healthcare system that truly meets the needs of all patients.

Tiffany Harman RN, MSN, is the global coding and clinical content manager at Solventum.