Managing population health with analytics and social determinants of health

Knowing more about a patient than ever before means healthcare providers are in a position to better serve high-risk populations.
By Benjamin Harris
12:04 PM
Managing population health with analytics and social determinants of health

Hospitals always want to do better. They keep tabs on the materials they use, the procedures they perform, and the patient outcomes after care.

What happened?

Factors like these help them assess risk when considering which actions to take later on. This kind of data gathering, however, doesn’t look at many of the upstream factors of the person receiving care that aren’t directly related to their health.

These social determinants of health don’t immediately impact clinical care but can inform on a patient’s life circumstances and ability to receive regular care, things which can greatly impact the cost and quality of their care overall.

Recently the consulting company KPMG worked to incorporate Waystar’s social determinants of health data into its performance analytics to better forecast care models for high-risk populations. Representatives from both firms share their experience with social determinants of health’s impact on care.

Why it matters?

Understanding social determinants lets a provider “look at patient populations and look at how to get them resources they need,” said Ryan Bengtson, senior vice president of corporate alliances at Waystar. Everything from knowing where food deserts are and which patients are situated in them to how well a patient’s access to the internet is can help hospitals offer better care, he stated.

Gleaning insights into factors outside of the clinical realm “becomes an additional thread of performance or process improvement,” Bengtson said. Knowing what circumstances a patient might experience, ranging from a person’s access to transportation to their food security or level of education, helps clinicians find easy-to-solve problems outside of the care environment that can have a huge and costly impact on a patient’s well-being.

“We’re finding some variations in care/cost outcomes that are heavily influenced by social determinants of health factors we didn’t have insight on before,” Bengtson said.

What is the trend?

As a better picture can be painted about patient populations, clinicians can better target populations who may be in need of additional services. These small upfront costs can help reduce the need for more major and costly treatment later on.

Larry Burnett, RN, principal at KPMG, says that knowing more about a patient’s environment and health-adjacent factors enables a much more stable care relationship.

“When we look at economic stability, how patients access healthcare resources, the access they have to primary/follow-up care...all of those areas for us are areas of risk and until recently we didn’t have much insight into them,” he said.

Burnett added a more detailed picture about a patient’s social determinants can make a major difference in how to best manage long-term care. Knowing a patient’s access to transportation can vastly improve treatment for someone who needs regular medical appointments but may not have adequate access to a ride.

“Those are types of patients with chronic conditions that are better managed if we know degree of risk beforehand,” Burnett explained.

On the record

Knowing where best to allocate resources and focus upstream care helps providers reduce barriers to necessary care and the causes of other kinds of visits to a practitioner that can be avoided. Burnett sees the use of social determinants-influenced analytics as being a way to help anticipate care requirements for all kinds of patients eventually.

“I think hospitals can use this to provide foundational services to all kinds of patients,” he says.

Benjamin Harris is a Maine-based freelance writer and former new media producer for HIMSS Media.
Twitter: @BenzoHarris.