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Data digging into social determinants of health

John Glaser and Tanuj Gupta, M.D., write in Hospitals & Health Networks about  providers’ using data to more holistically  understand their patients. Among their remarks:

  • “Look for links between geographical ‘hot spots’  that have high medical costs and relevant SDOH {social determinants of health} in those areas.
  • “Identify patients with risk factors related to SDOH .
  • “Classify patients into groups based on health outcomes, utilization, cost or other relevant factors and divide them into low risk, rising risk and high-risk subgroups.
  • “Link rising risk and high-risk patients to the appropriate community resources or care provider to help them mitigate their risks.

“Providers can apply analytics to entire communities to do a comprehensive community health needs assessment. They can assess gaps in social and clinical needs, select priority community health issues and plan improvement strategies. For example, a study of the data might reveal a large prevalence of homelessness in a geographic area that is also a ‘hot spot’ for high medical costs. Public libraries often become a safe place for homeless people to take shelter.

“The health system and the public library may be able to work together on programs to address health issues and homeless issues. If a geographic region has lower-than-average availability for affordable housing due to restrictive zoning, the health system might partner with a law firm to help address zoning issues in the area.’’

To read their whole report, please hit this link.

Lessons for healthcare system from treatment of the homeless


An article in STAT notes that “to make health care more accessible and higher quality, insurers and providers are experimenting with a number of new approaches — from storing patient information in the cloud to opening clinics inside of grocery stores.

“Close cousins to many of these tactics, however, were implemented even earlier in the homeless health care system. Homeless patients’ unique characteristics — they frequently have multiple chronic conditions, they move around often — overlap with some of the pressures driving medicine’s evolving care model today. And the cost and time constraints of the homeless revealed the weakness of the healthcare system before others saw it.”

Here are four elements in the treatment of homeless people applicable to other parts of healthcare:

  • The use of electronic health records.
  • Mixed providers in one setting.
  • Transitional care.
  • Bringing care to the patients.

To read the story, please hit this link.


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