3 ways to use social determinants of health data for better care management

Published: August 13, 2019 by Experian Health

When nearly 80% of health outcomes can be traced to non-medical social and economic factors, we need to look beyond the medical world to improve them. Perhaps a lack of transportation prevents a patient from attending an appointment, or juggling two jobs makes it difficult to collect a prescription. Maybe a patient’s care plan calls for lifestyle changes that are simply unrealistic in their current circumstances. When life gets in the way, there’s only so much the physician can do.

Creating and maintaining a healthy, happy population truly takes a village – from your clinical team to the community resources around your organization.

For many healthcare providers, there’s probably a lot more going in their ‘village’ than they realize. Do you know who your patients really are, beyond their lab tests? Do you know what nearby services are at your disposal to help you offer the best possible care?

Knowing your patients and your health improvement ‘village’ means you can offer a personalized experience to your patients, to improve their care management and ultimately help them achieve better health outcomes.

3 ways to tailor care management for better patient outcomes

Let’s imagine two patients, who have both recently broken their wrists and been treated in your facility.

Gene is 71 years old and David is 34. From the clinical perspective, it might be reasonable to assume that David, being younger, should simply receive discharge directions and a time for a follow-up appointment, and be on his way. Gene, being older, might require a series of follow-ups.

But thinking of the village analogy, is there more you could learn about Gene and David to engage with them in a way that’s tailored to their specific needs? Here are three ways social determinants of health data can help you do just that.

  1. Use non-clinical data to get to know your patients

Non-clinical data can help you learn more about your patients and the lifestyle factors that might affect their health. This allows you to address issues like excessive healthcare utilization, preventable readmissions, no-shows and low patient engagement.

Surveys at the point of registration are one way to get fresh socio-economic insights. But these can be cumbersome to implement, and findings can be limited by the nature of the questions.

You might also review geographical and community-level data to discover your local population’s income, housing situation, employment status, and so on. This can be useful for population-level care planning, but it’s not patient-specific.

A better way is to analyze securely collected marketing data for more specific and accurate information. This could tell you that Gene’s living situation actually has a minimal impact on his ability to access care, healthy food and reliable housing. Additional follow up appointments may still be appropriate, but perhaps less urgent.

By contrast, you might find that David has limited access to care because he lives alone and far from public transportation. His lifestyle suggests he’d be unlikely to prioritize getting gas to drive to a follow-up appointment over getting to work. In this situation, a remote health appointment might be the better plan.

  1. Know your community resources

Once you know what David and Gene might need, you can point them towards any appropriate community resources to increase their chances of a quick recovery. Of course, to do this, you need to know what and where these resources are.

For example, can you link David to an appropriate home health or telehealth program, or is there a non-emergency medical transportation service in your area to get him to his appointments on time?

If Gene needed support to follow a healthier diet, would a local food bank be available?

If either had an unstable living situation, would you know which local or national housing coalitions could help put healthcare within reach?

Tools such as NowPow, Aunt Bertha and Healthify exist to connect the dots between patients, providers and wider community resources, and close the gap in holistic care.

  1. Be proactive and preventative by holding conversations with your care teams prior to seeing patients

When you have reliable insights and data analytics to anticipate what patients like David and Gene might need, you can work with your care teams to develop a shortlist of options ahead of time. In this way, they’ll have realistic and ready-to-use solutions to give the patient right there and then.

To truly get the most out of social determinant of health data, your care coordinators need easily digestible patient profiles which they can understand and use in a split-second.

Bringing the whole patient into the care plan

Healthcare is growing more and more sophisticated in identifying ways to better manage care for patients by using data science and machine learning to predict health events. These insights help coordinate care plans that are preventative and proactive. Essentially, it’s about knowing your patients as well as possible, and being able to quickly match them to the services they need.


Discover how we can help you leverage social determinants of health data for your patient population, so you can bring in the whole ‘village’ of resources to support them on their healthcare journey.

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