DATA MANAGEMENT TECHNOLOGY &
unsafe area, can’t afford co-pays and prescription drugs, and lacks transportation. We can measure social risk objectively and see how reducing that risk improves health outcomes. Our standardised, self-reported social
determinants of health (SDOH) 15-item questionnaire, provides care teams with information about the patients’ SDOH that can make it harder for them to get healthy, such as a lack of transportation, which prevents people from getting to the doctor for an appointment or to a pharmacy for a prescription. A patient who screens positive for one or more social determinants is connected to resources that can address those needs, helping to improve health outcomes. This screening tool allows us to take a targeted approach to addressing social determinants, so we can more effectively help our most vulnerable patients get well. The majority of our inpatients treated annually at the hospital will be screened within 48 hours of admission. In addition, the aggregate data we collect will inform how we can make community-specific investments. Because SDOH predicts 80% of clinical
outcomes, they are very important factors in improving the total health of the patients and communities we serve. To be able to address SDOH, we must be able to identify those who are most vulnerable, where they reside and what social issues they are facing. To do this, we are developing two indices – a patient-level social vulnerability index (SVI) and a community vulnerability index (CVI) – based on predictive analytics informed by both community, and individual clinical and social data. It is important for healthcare practitioners to understand the level of a patients’ SDOH risk at the point of care, similar to seeing and understanding what is currently in the electronic medical record around clinical history.
Redefine community health strategies Northwell is committed to identifying and addressing the social determinant of health needs, especially in value-based care arrangements and linking patients to resources that will complement clinical care to improve overall health outcomes. To meet this goal, NowPow – a community-based resource referral IT vendor platform – is used to refer and connect Northwell patients to high-quality community resources, track the status of referrals and close
52 | Outsourcing in Clinical Trials Handbook
the loop with community-based organisations. The platform helps inform a data-driven strategy to target SDH needs of patients and the impact of SDH referrals on community health outcomes. This closed-looped referral management system allows Northwell to develop and refine community health strategies.
“Northwell is committed to identifying and addressing social determinant of health needs, especially in value-based care arrangements and linking patients to resources that will complement clinical care to improve overall health outcomes.”
Combining all three tools will allow us to
generate real-time data on social needs of patients, prioritise them and develop actionable recommendations on how to act on them. These tools identify the greatest social needs in our most vulnerable patients and communities, so that problems can be addressed through referrals to community-based organisations and via community-level initiatives. This reduces inappropriate utilisation of the emergency department, inpatient services and 30-day readmissions, thereby reducing healthcare costs for our safety net system, while also improving the health and well-being of our most valuable service area resources, and its residents. It will also improve patient experience and increase market shares. Currently, hospitals document social
determinants in patients’ electronic medical records, with codes that are used to note non- medical factors influencing health status and healthcare – called ‘Z codes’ included within the International Classification of Diseases, 10th Revision (ICD-10). This ensures that healthcare providers are aware of factors that may impact their patients’ health and allows interventions to be tracked, and assessed. It also provides a rich resource for research and helps Northwell identify the most pressing socioeconomic issues facing its communities, and adjusts its population health efforts accordingly. In addition, the data we collect can help create policy change around ICD-10 social codes to enhance payments for those patients with SDOH. ●
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