How to Take Control of Your SDOH Data

Augusta Health, a healthcare organization with a strong emphasis on population health, recognized the importance of addressing social determinants of health (SDOH) to enhance patient care and meet emerging regulatory requirements. This case study outlines their journey in developing and implementing an effective SDOH screening process.​

Background

Prior to formal mandates from the Centers for Medicare & Medicaid Services (CMS), Augusta Health had been proactive in collecting SDOH data. Their involvement in an Accountable Care Organization (ACO) facilitated initiatives such as building community partnerships, utilizing the Area Deprivation Index, and striving to meet quality measures for ACO performance. These efforts underscored the organization's commitment to understanding and addressing the social factors impacting their patient population.​

Challenge

With the introduction of CMS's health equity mandates, Augusta Health faced the challenge of formalizing their SDOH data collection to align with regulatory requirements while ensuring the process was patient-centered and integrated seamlessly into their existing workflows.​

Solution

1. Collaborative Learning: Augusta Health joined the Virginia Hospital and Healthcare Association’s (VHHA) health equity learning collaborative. This engagement provided insights into best practices for formulating SDOH screening questions that are comprehensible and comfortable for patients. For instance, simplifying terminology—like clarifying the term 'utilities'—was emphasized to enhance patient understanding.​

2. Screening Tool Development: Leveraging knowledge from the VHHA collaborative and CMS guidelines, Augusta Health developed an SDOH screening tool tailored for their inpatient population. This tool was integrated into their Meditech Electronic Medical Record (EMR) system, facilitating efficient data capture and accessibility.​

3. Mobile Clinic Implementation: Recognizing access barriers faced by certain communities, Augusta Health launched a mobile clinic targeting Hispanic populations that are uninsured or unable to visit the hospital. This initiative aimed to proactively deliver primary care services to underserved areas, thereby addressing identified SDOH challenges directly.

4. Organizational Commitment: The Augusta Health Board of Directors revised the organization's mission statement to reflect a heightened focus on health equity and inclusivity. This strategic move involved listening sessions with diverse employees and consultations with community partners, ensuring a comprehensive approach to health equity.​

5. Strategic Planning: A health equity strategic plan was formulated for 2023, with ongoing efforts to develop the 2024 plan. These plans are designed to document goals and strategic priorities, ensuring that health equity initiatives are substantive and not merely regulatory checkboxes.​

Results

The initiatives led to several positive outcomes:​

• Validated Insights: The data collected affirmed existing knowledge about patient needs, reinforcing the importance of targeted interventions like the mobile clinic.​

• Enhanced Patient Engagement: By simplifying screening questions and making them more relatable, patient responses became more accurate and informative, aiding in better care planning.​

• Proactive Care Delivery: The mobile clinic facilitated proactive healthcare delivery to underserved populations, improving access and potentially leading to better health outcomes.​

• Organizational Alignment: The revised mission statement and strategic plans ensured that health equity remained a central focus across all organizational activities.​

Future Directions

Augusta Health plans to leverage tools like the Medisolv Equitable Care Module to track and analyze SDOH data effectively. Future efforts will focus on utilizing collected data to identify and address barriers to care, incorporating health equity considerations into clinical outcomes, and ensuring continuous improvement in patient-centered care.​

Conclusion

Augusta Health's comprehensive approach to SDOH data collection and utilization exemplifies a commitment to health equity. Through collaborative learning, strategic planning, and targeted interventions, they have established a framework that not only meets regulatory requirements but also enhances patient care and community health outcomes.