Social determinants: a must for value-based care and population health

Experts contend that healthcare providers are starting to catch on to the importance social determinants of health play at the individual and patient population levels and that, increasingly, the factors will inform how they can ultimately improve care.
By Diana Manos
07:30 AM
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Health Quality Advisors president Michael Millenson said that healthcare organizations cannot make the transition to population health and value-based care without engaging patients and that requires addressing a number of challenges. 

Managing social determinants within population health is critical to improving outcomes, closing care gaps and lowering the cost curve.

As obvious as it might sound that the social and cultural networks people either have or lack can make a major impact on health, many healthcare organizations are just now starting to put two and two together on this issue, according to Karen Handmaker, vice president of population health strategies at IBM Watson Health.

Most likely this is happening because the pressure is on for providers to start thinking more about what happens outside of a doctor’s office and how it affects the patient. Despite new efforts, “none of this happens overnight,” Handmaker added.  

Reena Pande, MD, chief medical officer at AbleTo, echoed that sentiment. AbleTo offers a behavior change solution aimed at improving patient outcomes by treating behavioral health issues that interfere with medical care.

“If you don’t address the behavioral health of patients,” she added, “you can’t address the rest.”

Care teams must address the emotional blockers many patients have, including behavioral, stress, depression, bereavement, and caregiving challenges, Pande said.

The ultimate success of more advanced care delivery models — notably population health management and value-based care — will rely in no small part of including social determinants of health to shape a more comprehensive view of patients.

“You can’t get where you want to go without patients going there with you,” said Michael Millenson, president of Health Quality Advisors.

Integration of behavioral health into mainstream healthcare is one of the most promising of patient interventions, Millenson added. Behavioral issues often drive healthcare costs, so there’s an economic incentive to treat people holistically.

“We need to understand that purely physical ailments still come in the context of a real person’s life, and nothing is ever purely physical,” Millenson said.

Getting patients involved can help to overcome some of their psychological barriers to care.

While IBM and other organizations are conducting research on personality types and looking at behavior to recommend interventions that might be useful to more quickly anticipate what would work for certain patients, Handmaker said none of this will be accomplished overnight.

“Social determinants are going to inform where we go and how we can improve patient health,” Handmaker said.


 Social determinants will be among the topics at the HIMSS and Healthcare IT News Pop Health Forum in Boston, April 3-4, 2017. Register here.​
⇒ Pop Health Forum to address value-based care, executive leadership, innovation
⇒ Partners Healthcare uncovers twist, and savings, in population health data
⇒ Palmetto exec on overcoming telehealth funding and physician reimbursement challenges


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