Population Health: Addressing Social Determinants Through Digital Technologies
In the quest to develop lower-cost, patient-centered delivery models, healthcare organizations are focusing increasingly on the “social determinants of health,” or SDOH. These are aspects of a patient’s environment and lifestyle—such as housing, food, finances, education, employment, and transportation—that can directly affect health. For example, a medical condition can be exacerbated by a lack of access to healthy food choices, difficulty getting to doctor’s appointments, or unsupportive family dynamics.
Studies have found that individual behavior, often driven by social determinants, accounts for up to 40 percent of the risk of premature death. SDOH also include the presence or lack of personal support networks; research has revealed that social isolation is as much a threat to longevity as obesity.
In an effort to promote environments conducive to optimal health, more than two-thirds of healthcare organizations now assess populations for SDOH as an integral part of care management. Programs such as Healthy People 2020, an initiative of the U.S. Department of Health and Human Services, aim to address SDOH nationwide and to achieve health equity for all.
Reaching beyond the four walls of care
“If you don’t pay attention to social determinants, they can lead to worse health outcomes and make it difficult to thrive in the new world of value-based care,” says Dunnie Norman, senior vice president of sales at Vivify Health, an international digital health company.
“Historically, we have focused on care in a reactive way, looking only at what’s going on inside the body. But health and wellbeing are influenced by a host of other considerations, from the social environment to the ability to access health services. Many of the challenges of healthcare delivery, such as emergency room overuse or avoidable readmissions, are directly affected by these social determinants.”
Forward-thinking hospitals, health plans, and accountable care organizations are seeking tools that effectively address SDOH. A key solution is remote patient monitoring (RPM) and virtual care.
“With RPM, care becomes proactive. It moves outside the four walls of the hospital and traditional clinical care to focus on the factors that are not controlled inside the hospital and may negatively affect health. Through phone and video conferences and interactive surveys, the clinical team can gain key insights into a patient’s daily life and intervene as needed—anytime, anywhere—to help patients avoid escalating risk and stay healthy.”
Raising patient and family awareness
“Using virtual care, clinical teams see what’s going on within the home setting,” says Robin Hill, vice president of clinical solutions at Vivify Health. “It’s an opportunity to educate patients and potentially engage family members, who can provide insights on behavioral and health issues that the patient may be hesitant to share.”
For example, the family may observe that a patient is showing signs of depression and, as a result, isn’t eating well or is struggling with activities of daily living. The care team can intervene through a video call and connect the patient to additional resources, such as a behavioral health specialist and nutritionist.
“Through ongoing education and interaction, RPM can help improve health literacy for patients and their families. Lower health literacy contributes to poor health, ineffective management of chronic conditions, increased use of inappropriate care, more hospitalizations, and higher costs.” Studies have found only 12 percent of American adults are proficient in health literacy.
Reducing health disparities
RPM is helping to increase health equity by delivering “instant-on,” low-cost access to health information. “It’s a powerful tool for engaging vulnerable populations that have been underserved,” Hill says.
This technology is particularly promising for rural Americans, whose health is often affected by greater geographic isolation, lower socioeconomic status, higher rates of risky behaviors, and fewer job opportunities. Research indicates that rural residents are older, poorer, have a smaller cadre of physicians to care for them, and face more transportation challenges in accessing healthcare providers.
“RPM helps bridge the gaps created by geographic differences, while ‘bring-your-own-device’ solutions, such as Vivify’s Pathways +Go, engage patients on a large scale and broaden access to care for the most medically underserved populations.”
Reinventing population health management
As healthcare providers accelerate their journey to population health management, staying connected with high-risk patients is one way to prevent conditions from escalating and to avoid hospital readmissions. RPM can improve provider and health plan understanding of population health to more accurately predict and manage risk, as well as offer patients continuous education and support for better decision-making.
“Healthcare organizations need to understand which patients within their populations have certain social determinants of health, build care models that address these factors, and create connections that align patients with the right resources,” says Norman. “Remote patient monitoring is an essential tool in this effort—helping healthcare organizations to consistently improve overall health outcomes and to be truly accountable for all populations they serve.”