Bob Pascasio of Texas is a Community Healthcare Organization’s Administrator focused on building relationships and strengthening connections with peers and partners in business. Below, he emphasizes the pivotal role of social determinants of health (SDOH) in shaping outcomes for rural hospitals. From economic stability to education and community support, these factors weave a complex web that can significantly influence patient well-being.
By understanding and leveraging these determinants, rural hospitals can transcend traditional healthcare boundaries, offering more comprehensive and effective care to their communities.
We have long recognized that Social Determinants of Health, also known as “non-medical drivers of health,” play a critical role in the health and well-being of the communities we serve. As payment and reimbursement models, including Medicare, shift to outcomes-based measures, understanding and leveraging SDOH to benefit the organization has become imperative for rural hospitals, shares Bob Pascasio.
Bob Pascasio Explains More on Social Determinants of Health
The U.S. Centers for Disease Control and Prevention (CDC) defines SDOH as "nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age." These include a wide array of factors such as economic policies,
social norms, social policies, and political systems. The CDC has adopted this definition from the World Health Organization (WHO).
In simpler terms, SDOH encompasses elements such as whether individuals have stable housing, can afford air conditioning or heating, and have access to healthy food options. Bob Pascasio of Texas explains that these factors are critically important in determining overall health outcomes, particularly in rural areas where resources can be more limited.
Why Leveraging SDOH is Crucial
Attribution
Attribution refers to the process where capitated plans pay based on the number of lives served. Patients are attributed to the healthcare provider or system where they receive the majority of their care. Ensuring that these patients remain within your organization is essential for maintaining financial stability and improving health outcomes.
Managed Care Organization (MCO) Contracting
Bob Pascasio of Texas reports that
whole person care, which considers of all aspects of a patient's life and health, can significantly lower costs. Engaging with MCOs to incorporate SDOH into care models can enhance Quality Assurance and Performance Improvement (QA/PI) efforts, positioning the organization for future success.
Patient Connectivity
Additionally, leveraging SDOH allows providers to understand their patients better, fostering deeper connections and more personalized care plans. This improved understanding can lead to better patient adherence to treatment plans and overall health outcomes.
Reimbursement
Medicare and many Managed Care Organizations (MCOs) recognize the importance of SDOH and are beginning to reimburse for activities that address these determinants, particularly through Annual Wellness Visits (AWVs). This shift provides a financial incentive for rural hospitals to integrate SDOH into their care models.
How to Implement SDOH Strategies
Participation in Accountable Care Organizations (ACOs)
ACOs often provide toolkits and templates to help healthcare providers collect and utilize SDOH data effectively. Participating in an ACO can streamline the process of integrating SDOH into patient care.
Performing Annual Wellness Visits
Moreover, Bob Pascasio notes that Medicare now pays for activities identifying SDOH needs as part of AWVs. Incorporating SDOH assessments into these visits can help identify needs and align care strategies accordingly.
Utilizing Electronic Medical Records (EMRs)
Electronic Medical Records (EMRs) have become an indispensable tool for providers, particularly in rural hospitals where resources are often limited. One of the most significant advancements in EMR technology is the integration of modules designed to collect and analyze data on Social Determinants of Health. These modules can identify and address a range of factors that impact patient health, such as socioeconomic status, education, neighborhood and physical environment, employment, and social support networks. Leveraging these capabilities can significantly enhance the efficiency and effectiveness of care provided by rural hospitals.
EMR Modules for SDOH Data Collection
Modern EMRs are equipped with modules that allow healthcare providers to collect detailed information on these factors. These modules typically include:
- Screening Tools: Standardized questionnaires and assessments that patients can complete during visits.
- Data Integration: The ability to incorporate data from various sources, including social services and community organizations.
- Alerts and Notifications: Automated alerts that notify providers when a patient’s SDOH data indicate potential health risks or barriers to care.
Benefits of Leveraging EMR Capabilities for SDOH
• Holistic Patient Care
By understanding the full spectrum of factors influencing a patient's health, providers can deliver more personalized and effective care. For example, recognizing that a patient lives in a food desert can lead to interventions like nutrition assistance or connections to local food banks.
• Proactive Interventions
EMR alerts can prompt providers to address SDOH-related issues before they escalate into more serious health problems. This proactive approach can prevent hospital readmissions and reduce healthcare costs.
• Improved Patient Engagement
When patients see that their healthcare providers are aware of and addressing their broader life challenges, it can enhance trust and engagement. This is particularly important in rural areas where patient-provider relationships are crucial.
• Resource Allocation
Rural hospitals often operate with limited resources. By leveraging SDOH data, these hospitals can allocate resources more effectively, prioritizing interventions for patients most at risk.
• Collaboration with Community Organizations
Integrating SDOH data into EMRs can facilitate collaboration with local organizations and social services. For example, a patient struggling with housing insecurity can be referred to a local housing assistance program directly from their EMR profile.
Engaging with Vendors
Contracting with companies that provide case managers and other support services can help address identified SDOH needs. These vendors often have the expertise and resources to manage complex cases and coordinate care across multiple providers.
Addressing Identified Needs
Identifying SDOH needs is only the first step; it is crucial to address these needs promptly and effectively. Depending on the size and resources of the organization, it may be necessary to partner with community organizations to provide comprehensive care. Forming alliances with local non-profits, government agencies, and other healthcare providers can help fill gaps in services and ensure that patient needs are met.
Community Partnerships
Bob Pascasio of Texas explains that building strong community partnerships is essential for addressing SDOH in rural areas. These partnerships can provide additional resources and support services that may not be available within the hospital. For example, working with local food banks, housing authorities, and transportation services can help address some of the most pressing social determinants affecting patient health.
Available Resources and Toolkits
There are many toolkits and resources available to assist rural hospitals in leveraging SDOH. The
Rural Health Information Hub is a valuable resource for guides and information on best practices for addressing SDOH in rural healthcare settings. These resources can provide actionable insights and strategies for integrating these methodologies into patient care effectively.
Conclusion
Leveraging Social Determinants of Health is not just a strategy for improving patient outcomes; it is an essential component of modern healthcare that can lead to better financial stability and enhanced patient satisfaction. Bob Pascasio of Texas underscores that for rural hospitals, understanding and addressing SDOH can help build stronger, healthier communities and ensure that healthcare providers can meet the evolving needs of their patients.
By recognizing the importance of SDOH, engaging in effective community partnerships, and utilizing available resources and tools, rural hospitals can make significant strides in improving the health and well-being of the populations they serve, as well as ensuring long-term viability for the organization.
