Tag: sdoh

When it comes to the patient journey, knowledge is power. That's where targeted patient outreach comes in. Informed patients can make better and faster decisions about their healthcare. By arming patients with answers and easy access, they’ll be less likely to miss appointments or fall behind on payments. Instead, they’ll enjoy better health outcomes and a more satisfying healthcare experience. As digital services evolve, healthcare providers need to find new ways to engage patients. That means embracing digital tools and data analytics to make sure patients get the information they need through their preferred channels, and at a time that makes them most likely to act. Knowing what patients need gives providers the power to communicate with more patients, more effectively, and deliver outstanding patient experiences. This article looks at three specific use cases for targeted patient outreach. These include reducing pressure on staff, closing gaps in care and streamlining patient collections. Use case 1: Targeted patient outreach can help reduce pressure on call center teams and increase appointment bookings One of the biggest pain points for patients is having to schedule appointments by calling a specific number at a specific time, and then being put on hold until an agent is available to help. A recent survey by Experian Health and PYMNTS found that over the last year, one out of every five patients chose to skip this option and have booked their appointments through digital channels instead. Instead of just providing patients with a number to call during office hours, providers can make it even easier for patients to book appointments by deploying a patient outreach solution that connects patients to an online scheduler. Automated text message (SMS) and interactive voice response (IVR) campaigns can be used to send patients a link to schedule their appointment immediately. Waitlists can also be managed with this technology, by sending automated messages that enable patients to accept earlier appointments that may become available and cancel their existing appointments to make the slot available to others. Reminders are useful, but the ability to make an appointment is far more likely to result in bookings. Not only is this convenient for patients and enables them to see their doctor sooner, but it also helps offload call volumes for busy call center staff. Automated outreach capabilities can reach many more patients than a traditional call center setup. It can also process thousands of calls and messages per day without agent input. Use case 2: Targeting at-risk patients to close gaps in care Targeted patient outreach also plays an important role in closing gaps in care, so patients get preventative and follow-up treatment without delay. Historical patient data and data on the social determinants of health (SDOH) can be leveraged to identify at-risk patients and ensure they get timely, relevant and actionable information about their care options. For example, researchers in Pennsylvania found that patients with lung cancer were more likely to attend screening appointments after receiving some form of outreach, compared to those receiving standard care. Similar prevention-focused approaches have been suggested to identify patients at risk of chronic kidney disease, to address gaps in screening and early intervention. SDOH data and targeted patient outreach solutions can also be used to support populations that typically struggle with access to care, such as immigrant, minority and lower income communities. Outreach messages can include information about health education, local resources, links to book wellness visits and details of screening programs. Use case 3: Streamline patient collections and avoid lost revenue with targeted patient outreach In addition to tailored messaging around scheduling and health education, automated patient outreach solutions can be used to streamline patient collections with bill reminders and self-pay options. For example, PatientDial is a cloud-based dialing platform providing inbound and outbound automated calls. This speeds up collections by giving patients self-service options, such as balance retrieval, bill requests and pay-by-phone. Similarly, PatientText sends automated text messages with a link to a provider’s patient portal and contact center phone number. Frequency and content can be customized, and since there’s no send limit, providers can scale their campaign to as many messages as needed. Both tools reduce the need for agent involvement and provide insights to help improve performance. PatientDial in practice: Sanford Health used PatientDial in combination with Collections Optimization Manager to route collections calls to the appropriate agents based on the patient’s ability to pay. This led to increased collection rates. The system also generated $2.5 million in patient payments by verifying billing information, and an additional $60k was found through better management of accounts for deceased patients. Targeted patient outreach should be personalized, proactive and process-driven The key to success in each of these use cases is to be proactive. With the right data and patient outreach solutions, providers can anticipate the information that patients will need and deliver the must-know details in a tailored and timely format. Patients will be empowered to manage their own healthcare journey, while providers will lighten the administrative load and see higher collection rates. Find out more about Experian Health’s patient outreach solutions.

In the decade since the Affordable Care Act sparked the transition toward value-based care and pay-for-performance care models, clinical services have been transformed by advances in diagnostics, medical devices and digital technology. However, despite a commitment to improving care quality and patient experiences, the healthcare industry still struggles to influence the factors that have the greatest impact on patient outcomes – the social determinants of health (SDOH). It’s now well-established that clinical factors have a relatively small impact on a person’s health-related quality of life. As little as 20% of the factors that influence health outcomes are attributable to clinical care. The remaining 80% includes social, economic and environmental factors – such as access to safe and clean housing, healthy food, education and transportation. Healthcare providers cannot be expected to solve these challenges alone. That said, providers will benefit from developing plans and investing in systems that foster awareness of the social determinants of health that impact their communities. This will help enable the delivery of the proactive and coordinated services patients need to live healthier lives. The pandemic intensified many of the socio-economic barriers patients face when accessing care, medication, housing and food. It forced sudden changes to the way care was delivered, making it harder for healthcare organizations to sustain high-quality services. When overwhelmed hospitals just needed to get through the day, value-based care took a hit. To support underserved communities, healthcare organizations need reliable insights into their patients’ evolving life circumstances and socio-economic challenges. SDOH data can help providers identify the right strategies to serve their patient population in the most effective way. SDOH should be at the heart of patient-centric services. Healthcare organizations that prioritize the use of SDOH data are strengthening their ability to deliver value-based care. How has the pandemic affected SDOH and value-based care? Value-based care and pay-for-performance models were gaining traction just before the pandemic, and many providers were agile enough to respond quickly to the pandemic with telehealth and other remote services. But against a tsunami of COVID-19 cases, tests and vaccination programs, reimbursement models based on quality measures such as effectiveness, efficiency and timeliness proved fragile in the midst of an emergency. As is often the case, the worst effects of the pandemic were felt most acutely by marginalized and economically vulnerable groups. For example, groups with less stable employment were less likely to have access to sick leave or remote working opportunities, putting them at greater risk of catching the virus. Many community programs were put on hold, with consequences for the individuals who relied on them for food, support, and company. Insights on the social determinants of health can help providers segment vulnerable populations that need extra assistance to take control of their health. Once these populations are identified at the patient level with insights driving one’s unique SDOH risks, providers can develop strategies to ensure the right help is given at the right time. They can offer targeted outreach to ensure patients are able to adhere to care plans and access health checks, even take their medication as prescribed. This can reduce the risk of readmission, minimize hospitalizations, and keep healthcare costs down for both patients and providers. To supplement reliance on expensive and time-consuming patient surveys (that often leave out the “why” of a patient’s circumstances), Experian Health’s SDOH solutions combine analytical expertise, machine learning and proprietary data to generate actionable recommendations on the best way to address barriers to care, medication, housing and food. Combine SDOH and consumer data to personalize patient outreach The key to successful value-based and pay-for-performance care models is treating the patient, not just the disease. Data on SDOH allows providers to offer a more personalized healthcare experience, which is even more powerful when combined with consumer data. ConsumerView pools data on patient interests, psychographics, behavioral insights and broader lifestyle insights to give providers a 360-degree view of their patients. With this data, providers can offer relevant and timely advice to help patients overcome potential obstacles to attending appointments and complying with their care plan, such as information about transportation or childcare. It can be used to personalize healthcare communications too. Rather than blasting patients with one-size-fits-all healthcare information, communications can be tailored to patients’ preferred time and format, so they’re most likely to engage with the message. Making value-based care a reality starts with knowing who your patients are and what’s stopping them from getting the care they need. Find out how Experian Health’s Social Determinants of Health turn-key solutions can give your organization the insights needed to develop resilient and responsive models of care. With these tools, your organization can lay the groundwork to improve patient outcomes, regardless of the challenges that lie ahead.

As patient expectations shift, providers that offer a personalized healthcare marketing experience will be more likely to attract and retain satisfied consumers. The pandemic accelerated this shift. As a result, the traditional ways of healthcare marketing are starting to fall short. For example: A healthcare marketing strategy that’s designed for an “average consumer” results in a one-size-fits-all model that doesn’t always meet a patient’s individual needs. Communication options with fixed hours and channels don’t reflect “patient first.” Outreach messages blasted to an entire patient email list miss the mark for individuals who don’t speak the language or might prefer a quick text message instead. A study by Dassault Systèmes and CITE Research found that 83% of consumers expect products and services to be personalized within moments or hours. They’re accustomed to the “one-click” digital retail experience, which offers instant access to relevant recommendations and flexibility about how and when to buy. They’re also suffering from information overload, thanks to the sheer volume of emails, messages, articles and videos flooding their digital devices. Personalized communications can remedy that and help consumers feel respected and empowered, which drives connection and loyalty. But personalization isn’t just important for patient outreach. Personalized healthcare marketing can also help ensure patients get the treatment they need, by anticipating individual needs and highlighting relevant services at the right time. With the COVID-19 pandemic continuing to influence access to care, personalized healthcare communications can also be tailored for different patient segments. This can help reassure or remind individuals to book vaccination appointments or reschedule deferred care. Improve patient engagement with personalized outreach As digital offerings grow, consumer engagement expectations evolve. Providers must keep pace and communicate accordingly. Incorporating information about patients’ lifestyles, behaviors and preferences enables providers to deliver the right message at the right time. It also helps providers select and use the most effective channel of communication. Patients are more likely to respond and are empowered to manage their healthcare journey. For example, a Gen Z patient may prefer to receive appointment reminders by text, while an older patient may prefer a physical letter. One patient may prefer to get prescriptions mailed to their home while they’re at work, while another may be content to visit a pharmacy and pick up their medication while shopping nearby. Some patients will want a text message with a payment link to clear outstanding bills immediately, while others will appreciate a customized payment plan. Experian Health’s State of Patient Access survey 2.0 found that patients welcome proactive outreach by providers, though many say this doesn’t happen. Providers recognize the value in proactive patient engagement, but many say they lack the data to reach out effectively. With reliable consumer data and analytics, providers can create holistic profiles and deliver improved marketing to better serve new and existing patients. ConsumerViewSM pools data points on core demographics, behavioral insights, psychographic information and financial data to help providers understand their patients. This data can then be analyzed using Mosaic® USA and TrueTouchSM to segment, identify and reach the target audience with the most relevant message and format, and adapt based on consumer response. ConsumerView also adheres to consumer data privacy regulations, so providers can actively engage patients and build patient loyalty while confident in the knowledge that they have permission to use the data. Reduce readmissions and improve patient outcomes with better segmentation Personalized healthcare marketing isn’t just about messaging and channels. Providers that have a holistic picture of a patient’s lifestyle, life events, geographic changes and socio-economic challenges will be in a stronger position to anticipate their evolving wants and needs. For example, social determinants of health (SDOH) data can tell providers which patients may need extra assistance when visiting a doctor’s office, so that appropriate measures can be put in place. They might help identify patients with potential comorbidities that warrant proactive reminders about preventive check-ups. Similarly, providers can segment patients according to their financial situation. This can help with creating custom payment plans and sending timely payment reminders through targeted communications channels. Effective post-admission engagement can also help patients access the support needed to adhere to care plans, thus minimizing the risk of readmission and reducing unnecessary costs. A McKinsey & Co study found that around a third of patients with unplanned, high-cost follow-up care reported reasons that were considered avoidable, such as receiving unclear post-discharge instructions. Boost retention and recruitment with patient-centric and personalized healthcare marketing As rising medical costs and pandemic-related lifestyle shifts prompt more patients to shop around for care, providers must take action to create a healthcare experience that’s truly patient-centric. With data-driven healthcare marketing tools, providers can differentiate their services from other health systems vying for the same market. Find out how Experian Health can help your organization use consumer insights to build a patient-focused, personalized health marketing strategy to attract and retain satisfied consumers.

Mass relocations during the pandemic caused seismic shifts in healthcare markets. With millions of Americans moving and reshuffling to be closer to family or take advantage of remote working opportunities, healthcare providers have extra work on their hands to ensure their patient base holds steady. Some attrition is inevitable; however, as more patients relocate, providers may see more patient churn than usual. Unfortunately, this means more dollars in lost revenue. On top of this, consumers have changing expectations and more choices when it comes to healthcare, which means even more patients coming and going. Providers must find new ways to differentiate themselves in an increasingly competitive market for patient recruitment and retention. In June 2021, our State of Patient Access 2.0 survey revealed that attracting and retaining patients was a top revenue recovery strategy for providers hoping to make up for the shortfall caused by the pandemic. An Interview with the Expert, featuring Mindy Pankoke, Sr. Product Manager of Patient Identity and Care Management at Experian Health, sheds some light on the opportunities that lie ahead for patient recruitment and retention. Pankoke also explains how consumer data can help providers deliver an outstanding patient engagement experience. Watch the interview below:   How have patient recruitment and retention been affected by the pandemic? The pandemic changed how patients live and work. Many have relocated, while others have overhauled their lifestyles to find a better work-life balance and/or to pay closer attention to their health. Pankoke explains that these changes not only push patient recruitment up the priority list, but also require providers to take a bird’s eye view of their evolving markets in order to develop a better understanding of who their patients are. She says, “Waves of employment, unemployment and remote working mean patients’ locations and lifestyles have changed. As the dust settles, we’re starting to see how the market has shifted. It continues to be highly competitive, with multiple health systems fighting for the same patient base, so it’s important to know who’s new to your market, who might have moved out, and how COVID-19 may have impacted their lives. You can use that data to better engage with them and offer the most relevant communications.” How can data help providers with patient recruitment and retention? Understanding patients’ needs and preferences call for fresh and accurate consumer data. But which specific data points are most useful when it comes to patient engagement and recruitment? Pankoke suggests three areas to focus on: “Accurate contact information will make or break your patient recruitment strategy. Providers need to be able to reach the patient they’re intending to contact. Then, you can enhance demographic data by making sure you’re speaking to patients in their preferred language. Finally, marketing data can offer non-clinical insights about patients’ lifestyles so you can reach out and engage them more effectively.” Pankoke says it’s important to consider how the content and format of marketing communications might resonate with different patients. For example, a 50-year-old diabetic patient who has a job and lives in a multi-generational household will have a completely different lifestyle to that of a 50-year-old diabetic patient who is retired and lives alone. Consumer data can help providers see the full picture of a patient’s life, so they can offer the most helpful, sensitive and personalized information. Using data to “meet patients where they are” One way to stand out from the competition is to demonstrate an understanding of what patients need right now. Data on the social determinants of health (SDOH) can be used to enrich patient records, by providing insights into the non-clinical aspects of care and lifestyle factors that can affect a patient’s access to services. This is especially important given that socially and economically vulnerable groups were among those hardest hit by the pandemic. In our survey, 23% of providers said they were planning to or already implementing SDOH programs, up from 13% six months earlier. With SDOH data at their fingertips, providers can tailor their communications, so patients are supported to access the services they need at that moment in time. Reliable consumer data also helps providers communicate that information in the most appropriate way, to improve engagement, outreach and access. Pankoke suggests that some patients may prefer to learn about healthcare services through TV advertising, while others may prefer a leaflet or brochure through their door. Knowing your patients’ level of comfort with technology also means you can make better decisions about who to direct to patient portals or telehealth services. Get in front of patients before they start looking In today’s consumer-driven and competitive healthcare market, every touchpoint matters. Communications that are consistent, relevant and personalized are key to attracting and retaining patients. With the right data and digital tools, providers can anticipate patients’ needs, address obstacles and reach out to help patients stay on track with their healthcare journey. They can offer convenient and flexible options to register, schedule and pay for services – using a format that best suits each patient. In some cases, this means knowing what the patient needs before the patient knows it themselves. It’s a lot easier to get in front of patients with useful healthcare information before they start looking. Consumer data gives providers a head start so they can integrate SDOH and other patient information in patient recruitment and retention strategies that are proactive, rather than reactive. Watch the full interview with Mindy and download our State of Patient Access Survey 2.0, to find out how your healthcare organization can incorporate consumer data to communicate the right message in the right format to attract and retain loyal consumers.

This is the fifth in a series of blog posts that will highlight how the patient journey has evolved since the onset of COVID-19. This series will take you through the changes that impacted every step of the patient journey and provide strategic recommendations to move forward. In this post, explore the fifth step—treatment, and how social determinants of health can help your organization get a more holistic picture of your patients. To read the full white paper, download it here. How does a virus that does not discriminate produce such different healthcare outcomes across population groups? COVID-19 exposed population care challenges within the healthcare system. For example, data from the Centers for Disease Control and Prevention (CDC) consistently shows that American Indian and Alaska Native (AIAN), Black, and Hispanic people have a higher risk of COVID-19 infection, hospitalization, and death than their white counterparts. The AIAN community is 3.4 times more likely to be hospitalized due to the virus. An analysis shows that health disparities like these result in approximately $93 billion in excess medical costs and $42 billion in lost productivity per year. These differences in the health status of various population groups are socially influenced, unequal in distribution, and, most crucially, often avoidable. Arming clinicians with patient-level “Social determinants of health” insights can help When it comes to health outcomes and patient engagement, health providers can look beyond the immediate medical needs of a patient to understand non-medical factors that commonly act as barriers to accessing good healthcare and inhibit successful treatment. These can be things that influence a patient's social networks, socioeconomic situation, cultural and environmental conditions, as well as how they live from a health perspective. They are collectively known as social determinates of health (SDOH), and they account for up to 80 percent of health outcomes. Examples of social determinants of health include: Access to nutritious foods and opportunities for physical activity Access to transportation Education, job opportunities, and income Housing stability Language barriers and poor literacy skills Pollution and [lack of] access to clean water Racism, discrimination, and violence For example, a patient that suffers from a language barrier may have problems booking an appointment and understanding the steps for proper care. This can result in inconsistent treatment and poor treatment outcomes. A patient’s income can also play a part. Some patients may lose their jobs, move homes, lose access to cars, and more – resulting in food insecurity, housing instability loss of access to care and medication. According to a Gallup survey, 25% of patients defer treatment because it’s perceived to be unaffordable. It’s vital for healthcare providers to create a plan that includes touchpoints that screen for SDOH updates. Providers will need to actively educate their patients about alternative payment plans and other financial aid programs, to show their patients that care is accessible through a variety of resources. The benefits of addressing SDOH using digital solutions: to reduce health inequity and improve patient engagement Research found that integrating SDOH data into patients’ electronic health records and care plan considerations offered the potential for improved care and health. Adding this useful data allowed for a better understanding of patients’ social influences, as well as better collaboration between healthcare providers and community services – enabling patients to be treated and engaged from a holistic standpoint. When providers take SDOH into account and adjust patient engagement in care planning  accordingly, can alleviate: Readmissions Unnecessary emergency department visits Poor care quality ratings When employing an SDOH solution, providers can use data to develop new strategies that can target vulnerable populations. For example, SDOH research during the pandemic, conducted by the National Center for Biotechnology Information, revealed that school closures increased food insecurity for children, which led to greater rates of malnutrition. This led to lower immune system responses and increased the risk of infectious disease transmissions When trying to increase COVID-19 vaccination rates among populations living in low-income areas, healthcare providers can utilize SDOH data to develop ways to make care more accessible. Social determinants of health insights on access to care, medication, housing, and food barriers can also proactively identify patients with health inequity. Understanding differentiating drivers of individual SDOH profiles can help healthcare programs meet patients’ unique needs – ones that are hindering an equal playing field for their own health. Social determinants of health can help providers discover new opportunities Healthcare providers can also use this data to devise strategies to communicate more effectively with their patients, especially via the patient’s preferred channels. Technology and communication barriers that are typically overlooked should be examined as a part of SDOH. For example, a patient that prefers direct mail over email may ignore communications that they’re not receptive to. Meeting a patient where they are and through the channels they prefer is crucial to making a connection. Once they understand a patient's SDOH, providers can connect patients to relevant outreach or community programs that assist in removing some of the barriers to a patient's optimum care.  For example, if a hospital learns that their patient base has higher food insecurity, as opposed to access to care risk, they can work to prioritize partnerships with a local food bank or meal delivery programs. This allows providers to proactively help their patients make it easier to comply with their care plans when otherwise, a meal on the table would’ve taken priority over a wellness check. combining SDOH solutions with patient scheduling software, providers can automate proactive outreach for more and frequent follow-ups to encourage patient engagement. By utilizing social determinants of health (SDOH) insights, every patient visit becomes an opportunity to verify and address the non-medical factors that may be affecting the patient’s health and make better use of your organization’s community network. SDOH can help providers build robust patient profiles to display information that wouldn’t be visible in the clinical data. With Experian Health’s SDOH solution, providers can create robust profiles that can determine a patient’s readmission SDOH risk, and provide factors that are driving these risks. This solution can also provide recommended strategies that care team members can use to align appropriate resources and be proactive about their health outcomes. The healthcare system is designed to help patients during illness or injury.  However, delivering care equity is best achieved by also accounting for the non-clinical conditions that influence health. By looking at a patient holistically and combining clinical data with SDOH, providers can identify the unique challenges patients face and then tailor care to a patients’ individual needs. As providers adapt to life in the shadow of COVID-19 and move beyond crisis mode, it’s more crucial than ever to enrich patient identity management with SDOH, and close the gaps in care when the virus subsides. Missed the other blogs in the series? Check them out: 4 data driven healthcare marketing strategies to re-engage patients after COVID-19 How 24/7 self-scheduling can improve the post-pandemic patient experience COVID-19 highlights an acute need for digital patient intake solutions Automated prior authorization: getting patients the approved care they need

While the various waves of vaccine priority may be largely defined, the ability for many providers to segment their patient populations based on those designations isn't always simple. Without accurate data, there’s a risk that some vulnerable patients will be missed out. We interviewed Mindy Pankoke, senior product manager at Experian Health, about the challenges in segmenting patient populations for the COVID vaccine and how providers can best overcome those challenges. How does addressing patients’ barriers to care increase vaccination rates? The early versions of this vaccination have two doses which comes with its own set of challenges. Getting a vaccination is one thing but getting people to follow up for a second dose in a certain time frame is another. It’s the non-clinical factors that will prevent patients from getting the vaccine. So, things like inflexible work schedules, lack of transportation or even the access or comfort levels with technology required to schedule an appointment online can prevent patients from receiving or prioritizing the first and/or second dose. It can be an uneven playing field with those patients that do not have more flexible schedules, a vehicle or even access to the proper technology to schedule and register for both doses. It’s much easier for patients to prioritize getting the vaccine when those non-clinical factors are a non-issue. What challenges may providers face when trying to segment patient populations for vaccine administration? There are a lot of gaps in patient demographics which can make it difficult for providers to accurately identify and segment patients. Think information like date of birth or occupation. If providers want to segment by age, which many will likely do for the first wave of vaccinations, that would require a complete record of every patient with an accurate birth date. Providers may also want to segment by occupation, knowing essential workers are also eligible for the vaccine. But how can you understand who is an essential worker? Especially when that definition may vary by state or local government? Including non-clinical insights and enhancing demographic data as part of the patient record can help providers fill in the gaps and better segment patient populations for vaccine administration. By combining the power of Experian’s consumer demographic information with more than 40 years of experience compiling consumer data from self-reported and state license boards, Experian Health is able to drill down into occupation data to view different types of employment (construction, utility, etc.) for you to use to outreach, verify and streamline the scheduling (and automated scheduling) or the COVID vaccination. What are some best practices to move from identifying at risk or priority populations and operationalizing that information into actually administering the vaccine to those groups? This is really where it all comes together, and really where providers need to act fast. Once a group is identified, providers can automate the process as much as possible. First, it is imperative that providers clean up their data. Recent processing of Experian’s Universal Identity Manager solution has identified 1,800 duplicate records in COVID vaccination registrations, for individual facilities. Providers can remove the duplicates, enhance the demographics where they may be out of date or missing, and put in place a proactive system to call out and prevent duplicates moving forward. And the vaccine has a shelf life, correct? So even after segmenting the right patients, how can providers act fast to ensure it is administered? So another best practice is to automate the scheduling for as many vaccination appointments possible. With a tool like Patient Schedule, providers can leverage the demographic data to programmatically push out a notification to a patient’s cell phone via IVR or text message, have them verify their eligibility based on the age or occupation data from Experian, and then allow the patient to book their appointment on the spot for a time that works best with their schedule. On the back end, the Patient Schedule solution syncs with the clinic or mobile vaccination site’s calendar to confirm the appointment, allowing staff the opportunity to tackle other pieces of the COVID vaccination strategy. Anything else you'd like to add? Providers will also want to risk stratify using social determinants of health insight on the individual level. Patients in every wave of vaccine priority present an opportunity for better patient engagement (68% of the US is impacted by at least one social determinant of health hindering them from accessing or prioritizing their care). Many patients will need help adhering to that second dose and knowing that information and those circumstances on the individual level can help providers engage in the best way possible to ensure the vaccine is administered correctly. Interested in learning more about how Experian Health can help supercharge the COVID-19 vaccine management process?

As COVID-19 cases climb in the U.S., healthcare providers are strategizing on ways to prioritize testing for specific patient populations and determine overall treatment plans. Already, the world has identified that people age 65 and older, and those with underlying medical conditions, are more susceptible to severe symptoms from the coronavirus. Another group who could be at greater risk? Those individuals with barriers to health, like social determinants. Social determinants of health (SDOH) are the non-medical factors of healthcare that account for up to 80 percent of health outcomes. When patients struggle with access to care or access to medication, they’re less likely to follow treatment plans or show up to important follow-up visits. In the case of the coronavirus, some providers are now considering SDOH to flag particular data fields in an attempt to identify patients with access to care challenges, specifically where a remote health service or telehealth option would be especially helpful. Drive-thru coronavirus testing sites are popping up across the country, and healthcare facilities in all states are encouraging individuals to leverage telehealth solutions instead of flooding sites with in-person visits. SDOH screening could assist in proactively identifying individuals who need to be routed to different care channels. Consider the following: Patients screened for testing may live outside of driving distance to a hospital or clinic. Should these individuals be guided to a different testing option or alternative location? Some people screened for a test might live alone, without a vehicle, and are unable or unwilling to walk to a testing location. Those with symptoms are discouraged from using public transit, so is at-home testing a better option? Additionally, those who live alone without a vehicle may need a proactive check-in to ensure they have no untested symptoms. Could that help prevent a 911 call and additional stress on the emergency department? Proactively screening a patient population by  “access to care” data could enable a provider to  expand its coronavirus care strategy and consider information that might mitigate future surges in coronavirus cases and ED and clinic visits. Giving attention to patients or members with non-clinical needs and pairing them with the right engagement strategy before they require an escalated response can have a positive impact on clinical services. “Integrating SDOH data into clinical systems is something providers are just beginning to do, but the response required by COVID-19 presents an opportunity to accelerate that,” said Karly Rowe, Vice President of Product Development for Experian Health. “Identifying at-risk patients who may need help tapping into personalized screening and treatment options could help providers quickly suggest the ideal course of action for individuals, and at the same time conserve resources and contribute to the safety of staff and the larger community.” It’s early days of COVID-19, but data will certainly be a differentiator in managing the first pandemic in the 21st century. “Speed, efficiency and accuracy are critical in situations like what healthcare professionals are facing today,” said Rowe. “Innovative use of data is a big part of delivering on those.”

The stats are alarming: Up to 80% of health outcomes are not due to medical factors, but to a patient’s social and economic circumstances—such as their income, housing situation and even whether they own a car.68% of Americans are affected by at least one social determinant of health (SDOH).Approximately 24% of hospitals and 16% of physician practices screen for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence—which means the majority don’t screen for all relevant social needs. The healthcare industry has been talking about the importance of addressing social determinants of health for years, but many struggle with how to collect the insights. For example, if 68% of Americans are affected by at least one SDOH, how do they even discover the one? What is the ideal way for providers to screen for SDOH? Should they simply ask the patient? Do they start a visit with a survey, probing for details that could ultimately impact care management decisions? Providers know these sensitive topics – housing instability, financial instability, food insecurity and onward – can be tough and uncomfortable conversations. So, where to begin? Should you rely on patient surveys to capture SDOH? Patient surveys can be a useful way to find out about many potential barriers to care. However, they bring limitations: Your insights will be limited to the patients who show up—so anyone who has struggled to attend an appointment (and therefore potentially with higher needs) will be left out It can be time-consuming and expensive to give staff the time and space to conduct personal interviewsThey rely on patients to be willing to share openly, but some may not feel comfortable doing soThere is room for error in how questions and answers are interpreted by both the survey team and respondentsSocial circumstances can change over time, so it’s possible that the information gleaned in the survey may not be relevant a few months down the line. Knowing SDOH can have such a huge impact on a patient’s health certainly means clinicians should discuss these topics in the exam room, but relying solely on patient surveys and conversations could lead to gaps in intel. When should you screen for SDOH? Screening for social needs when a patient first registers or engages with your services is a good starting point. But what happens when their situation changes between diagnosis and treatment? What if they disclose a social need to a specialist that wasn’t flagged on their initial intake form? Does your staff know how to discuss sensitive social issues? Can they create a safe space for patients to share? Have you got clear referral pathways when an issue is flagged? Look for possible touchpoints in the patient’s journey where referrals to support services would be appropriate. Looping in the relevant primary care services is a good way to make sure your patients are connected to community-based programs and supported throughout their journey, whenever a new or changed social need is identified. What types of data could offer the SDOH insights a provider needs? Geographical and community-level data can help a healthcare organization understand their patient population’s income, housing situation and employment status. These are useful for population-level care planning but aren’t patient-specific. A better way is to analyze securely collected consumer marketing data for more specific and accurate information. Working with a trusted data vendor that is a compiler of original-source consumer data can help you navigate your options. The real predictive power of SDOH data comes when you combine patient-specific information obtained through screening, with consumer databases. A third-party vendor can help you access data on your patient population’s income, occupations, length of residence and other social and economic circumstances. Your care managers can use this to inform proactive, preventative conversations with patients to solve any non-clinical gaps in care. Bottom line … When healthcare organizations have a holistic view of patients—and the SDOH that play a role in their lives—they can take steps to help prevent avoidable hospital visits, emergency department (ED) utilization, appointment no-shows and worsened conditions by encouraging and facilitating earlier interventions. The key is to start with the right data.

  I attended the Fall 2019 Conference of the National Association of Accountable Care Organizations (NAACOS) in Washington D.C. and wanted to share some insights on how top-performing Accountable Care Organizations (ACOs) are using data to drive improved quality and cost of care. Over the last decade, we’ve seen the number of ACOs surge. Propelled by the shift from volume- to value-based care, over a thousand ACOs operate across the U.S., bringing together groups of physicians, hospitals and other providers with a collective ambition to enhance quality of care, reduce healthcare costs and improve patient outcomes. While some ACOs participating in the Medicare Shared Savings Program have succeeded in improving quality and realizing some savings for the program, the value-based model is still evolving, and results can be mixed. More dramatic and holistic moves will have to be made to convert today’s annual incremental savings of 1 to 2% to make a dent in the estimated annual waste of nearly $389 billion in administrative complexity and another $45 billion due to lack of coordinated care. So what separates the top performers from the rest? At NAACOS last week, speakers confirmed that the most successful ACOs are those that effectively shift care towards primary care physicians (PCPs) and away from acute settings and skilled nursing facilities, implement a process for continuous improvement and adopt a performance-first culture. This is easier said than done. Here’s my top recommendations to help ACOs leverage data-driven insights to lower costs while improving patient outcomes. Offering insights into member utilization of healthcare resources in real-time I recently worked with a client that needed real-time alerts of member activity including admissions, discharges, and Emergency Room (ER) visits. These insights enabled this client to proactively manage active member episodes of care, optimizing the setting and deliver of care for the member’s specific needs. For example, a member was frequently visiting the ER with complications from his Chronic Obstructive Pulmonary Disease (COPD) condition that the client’s care team was managing. This was a needlessly costly way to treat the symptoms. To help get their members the right care at the right time, this client started leveraging automated alerts for their members as they presented within the healthcare continuum. The next time this patient sought treatment in an out-of-network ER for their COPD, their primary care physician (PCP) received an alert about her patient as soon as they registered, before a doctor had even seen him, and certainly before an ER workup converted to an admission. The PCP called the attending ER doctor to share the patient’s history and ensured the ER physician that this patient would receive next-day follow-up care in the PCP’s office. Knowing that follow-up was in place and the patient wasn’t in immediate need of care, the ER physician discharged the patient home. Given that the average cost of an admission can run $22,000, and an outpatient visit less than $500, the savings delivered by this kind of care coordination becomes significant. More importantly, the member experience is much improved in that they get to go home instead of an unnecessary overnight stay in the hospital. And this is just one example—multiply this kind of episode management across all member encounters and consider the improved member quality of life across all attributed lives and the savings for the health plan or ACO in the aggregate. Real-time alerts provide a win-win for both patient and ACO by affording care teams the opportunity to optimize the setting of care for quality and cost. Care coordination for episode management To improve episode outcomes and reduce readmissions, visibility into the compliance of a patient’s post-discharge care plan through the duration of the entire episode is critical, so well-coordinated care requires that clinical context be shared between providers. A frequent barrier to this flow of useful data is that clinicians’ electronic health records (EHRs) aren’t always interoperable. To solve for this, some ACOs are attempting to move all their providers to a single EHR and care management module. However, for some this may not be an option. In these cases, ACOs can opt for Care Coordination Manager: a rules-driven, closed-loop messaging and distributed workflow orchestration platform that enables health plans, ACOs, allied health, and community partners to share and assign care plan requests across a diverse provider community. Care Coordination Manager is vendor-agnostic and able to populate EHRs and care management modules at the point of care with key clinical context. This flow of tasks and content supports high-quality coordination of care and management through transitions of care. Proactively address non-clinical barriers to health for improved patient engagement and health Another characteristic of top-performing ACOs is that they utilize a 360-degree view of their members to address potential barriers that prevent members from engaging in their own healthcare. These SDOH factors can include things like housing or financial instability, food insecurity, limited access to transportation or healthy food options, and other non-clinical factors. Only about 20% of costly health episodes are due to medical factors, so it’s vital for ACOs to incorporate a more comprehensive and actionable understanding of the social needs of the populations they serve. For example, medication adherence is a bigger challenge for a patient who may have difficulty getting to a pharmacy or understanding medication instructions. Identifying and mitigating these risks up front gives the patient a better chance of adhering to their prescribed regimen, which in turn gives them a better chance to stay healthy, ultimately lessening the disease burden and thus the cost of the ACO’s membership while improving the patient’s quality of life. ACOs can take a proactive, preventative approach to addressing these challenges by collecting and analyzing member data and using these insights to tailor interventions. Patient-supplied information through surveys, like PRAPARE, is a good starting point, but surveys can be limited by access to the patient as well as the patient’s ability or willingness to answer honestly. Additionally, unless mapped to structured data such as ICD-10 Z codes, survey data is challenging to scale for broader insights into the ACO’s membership. Instead, consider healthcare consumer data that’s sourced directly from a reliable vendor. Analysis of this demographic, psychographic and behavioral data allows you to flag patients based on need, so you can identify the best way to communicate with members to help them own their healthcare journey. For example, in a recent report by the Department of Health and Human Services’ (DHS) Office of Inspector General (OIG), one ACO described how asking patients with chronic conditions to make a daily call to a care coordinator led to 43% fewer emergency room visits and 47% fewer readmissions. As ACOs grow amidst pressures to take on downside risk and manage costs while improving quality—timely data collection, sharing, analysis and action will continue to provide the foundation of high-quality episode and population health management; along with engaging members and community partners in the healthcare journey. What’s clear from discussions at the NAACOS conference last week is that the opportunity exists to work smarter across many emerging payment models. Could data be the key to unlocking that opportunity? McLain Causey is Director of Product Management at Experian Health.