Ambulatory and Health System Perspectives

By EHRA Public Policy Leadership Workgroup

Part one of this two-part blog series summarized insights around SDOH and health equity from the developer and community perspectives, which were shared during the recent virtual Congressional Briefing hosted by EHRA’s Public Policy Leadership Workgroup. Part two shares the ambulatory and health system perspectives. The presentation slides and full briefing (passcode: H@R$UZ02) are available in the “Positions and Statements” section of EHRA’s website. 

The Ambulatory Perspective

Sarah Holder, Clinical Director of the 17-physician Raleigh Pediatric Associates in Raleigh, NC, represented the ambulatory perspective. She was integral to developing the practice’s SDOH program, which officially launched in 2019 and screens patients for food insecurity, housing and transportation, security, and personal safety. 

The practice leverages its existing registration app to conduct the SDOH screening questions and uses open API functionality to flag the information within the patient’s medical record when need is indicated. To act on the information obtained during screenings, a practice employee follows up individually with patients and families who are seeking assistance.

This approach lets the patient or family member “answer these questions in the privacy of their own home, outside of the office, without someone staring at them,” said Holder, which is important to building trust in the program “because these questions are very sensitive.”

A significant resource has been NCCare360, a statewide network that unites healthcare and human services organizations through shared technology that electronically connects those with identified needs to community resources. 

Congress, she said, can help by providing funding for these programs and eliminating financial barriers to seeking assistance. Offering incentives to other practices to launch similar programs is also needed, as many are unsure where to start.

“We want to see coverage for the associated social services bundled into the patient’s preventive care health coverage.” she said. “Building a successful program is resource-intensive, and incorporating social determinants of health screenings into a practice’s regular daily activities will need to be paid for by insurers and Medicaid to become common practice across the industry and for patients to widely benefit.”

The Health System Perspective

Seraphine Kapsandoy, Ph.D., RN, Chief Nursing Information Officer at Intermountain Healthcare, offered the health system perspective on how SDOH can help guide care decisions and support patients in living their healthiest possible lives.

“Addressing social determinants of health is mission critical for us if we hope to be a model for value-based healthcare systems,” said Kapsandoy. “For us, understanding and improving social determinants of health at an individual community policy level allows us to put health equity at the forefront and gives us the context of the lives that we touch.”

Intermountain, a 25-hospital nonprofit system in six states with a 900,000-member health insurance company, led the establishment of the Alliance of Determinants of Health, a community-based collaborative designed to proactively address factors affecting community health, such as chronic hunger, affordable housing, joblessness and personal safety. In addition to screening individuals in the clinical setting and connecting them to appropriate community resources, the Alliance is building a community network to coordinate care for physical, mental, and social needs. 

Some of those needs, such as trauma and intimate partner violence, highlight the opportunities for “interoperability and bidirectional communication platforms for data sharing and securing referrals, care coordination with social care referral platforms…and communication exchange with community-based and government organizations, including the ability to receive feedback directly into the EHR of the status and outcomes of social determinants of health when we serve the patient,” said Kapsandoy.

Opportunities also exist to adopt standards for SDOH coding and documentation that protect victims and ensure visibility into the electronic health record (EHR) in ways that enable real-time decision support and determination of the patient’s insurance status.

“At the state, national and international levels, there are challenges and barriers with the master patient index to facilitate data sharing and tracking of patients as they move across healthcare, community and government organizations,” said Kapsandoy, adding that an “area of opportunity is for standards for recording a person’s race, ethnicity, sexual orientation, disability status and other demographics, which will facilitate evaluation of health equity.”

She noted that Congress can play a significant role in eliminating barriers in three specific areas:

• Value-based reimbursement by establishing models focused on social needs and services by community-based organizations that include appropriate coding and provider reimbursement for clinical social care.
• Interoperability and regulations, such as the ability to share social and insurance data in real time, clarifications regarding HIPAA requirements specific to social care referrals, a national master patient index (MPI), and flexibility within Stark, patient inducement, and member recruitment regulations that impede social care assistance.
• Funding and rewards, such as waivers to support innovation and best practices in social care, technology to support social care coordination, and value-based social care reimbursement models for providers, states, and health plans.

Resources Required

Resources are desperately needed to assist those who “have landed in a place where basic human needs are not being met, such as food security, safe and healthy living environments, employment opportunities and opportunities for quality education,” he said. “Addressing those issues outside the healthcare environment will then have a measurable impact on their health outcomes, and even their life expectancy.”

Bucciferro concluded: “If Congress were to provide the necessary resources to ensure the availability of technology upgrades and information exchange such that community service providers in the disability and social service space could critically impact social determinants of health and health equities, it would be life-changing.”