Two innovators share how they revolutionized the SDoH space
Up to 60 percent of clinical outcomes are directly tied to the circumstances in which people live, work, and play — that is, by social determinants of health (SDoH). Yet despite the massive opportunity for impact, bringing effective SDoH interventions to life is rarely easy. Key questions from the outset include:
- How can community-based organizations work with clinical partners?
- How can data be shared to promote collaboration and track the effectiveness of SDoH initiatives?
- And ultimately, what is the long-term ROI to justify a new SDoH initiative?
In our latest webinar, Healthify founder and CEO Manik Bhat sat down with two leaders from Reading Hospital to explore answers to these questions and more.
How Reading Hospital is leading the way in addressing SDoH
Three years ago, Reading Hospital was the recipient of a $4.5 million federal grant from the Centers for Medicare & Medicaid Services (CMS). The goal was to position the health system as a vital "hub" in the area: a conduit between medical care and social services and the Medicare and Medicaid patients who benefit from them.
Desha Dickson, associate vice president of community wellness at Reading Hospital, has been at the forefront of this effort and has learned just what it takes to get a pilot SDoH intervention off the ground.
Dickson's advice is to start small. "Start with a small target population," she said. "Think of one, two or three social determinants of health to screen for. More than that can get overwhelming."
Another key ingredient, according to Dickson, is building effective, trust-based partnerships. In her experience, trusted partners will not only help prevent duplicative work but also improve the coordination of care delivery— in turn enhancing the overall efficacy of community-based approaches.
From there, Dickson moved on to the bigger picture: How do we sustain these SDoH initiatives once they're off the ground? And while there isn't a one-size-fits-all answer, Dickson says it certainly helps if you "think about sustainability from the beginning." At this point, for Dickson the biggest challenge is articulating the value of these new approaches to all stakeholders involved—and, as she put it, "translating that into new clinical opportunities to help people stay well."
More lessons from the front lines
To help make Dickson's high-level insights more concrete and actionable, Tanieka Mason, data manager and quality improvement facilitator for the Reading Hospital Community Connection Project, walked through some of the specifics of implementation.
One aspect Mason stressed is the importance of aligning on workflows with clinical partners. Even with the benefit of a full year of preparation and planning, Mason confessed, "I often felt like we were building the plane while flying it."
Early on in the implementation phase, Mason and her team began to notice things that no amount of planning likely would have accounted for. The type of clothing worn by those who were conducting screenings, for example, seemed to be influencing the efficacy of the ultimate interventions.
"When approaching patients in business attire, patients didn't want to open up," she said. When screeners were dressed more casually, on the other hand, that started to change. "Patients opened up about the issues they were having."
Likewise, given the large Spanish-speaking population served by Reading Hospital, having bilingual staff members was naturally an imperative. But, as Mason explained, other skills among staff were harder to screen for — and in some cases, impossible to teach.
"What it came down to is that there are certain skills we can't teach people," she said, "so we needed to make sure that the staff we were hiring came with those skills: empathy, compassion." She went on, "People who weren't afraid to walk up to a complete stranger and ask them these personal questions, and also show empathy and compassion for the answers."
Finally, Mason talked through some of the ways she and her team are working to close the loop in their work with clinical and community partners. And she specifically called out the important role that Healthify, by integrating data across different systems, has had to play.
"They're able to connect our needs and help us move the needle in this space," she said. "It's not just a system that we use. It's a partnership. Healthify really stands apart."
Big picture SDoH impact so far
In closing, Mason highlighted some of the impressive outcomes that Reading Hospital has been able to drive so far, including:
- 42,112 beneficiaries (more than a quarter of whom had at least one high-risk social need)
- 107,042 screenings
- 3,725 unique navigations with personal interviews or action plans
- 5,121 in-network referrals to CBOs
- 3,367 out-of-network referrals
To learn more about how Reading Hospital delivered impressive outcomes like these, operationalized its SDoH program and achieved ROI, watch the webinar now on-demand.