What are some ways that purchasers and providers can improve upon leveraging patient social determinants of health information in pursuit of the triple aim?
World-class, risk-bearing, population health management companies like Health Care Partners, CareMore, and ChenMed have long known that the best medical care is necessary but not sufficient for many of their at-risk / high-risk patients.
Frustrated by the fragmentation of care across the continuum and disenfranchised by the misalignment of payments and incentives, organizations such as these set out to care for their patients differently. They put the patient at the center of the care delivery ecosystem and broke down barriers that blocked what patients need. What they found was that truly transformative outcomes went hand-in-hand with superior financial performance. Further, they learned that to generate those transformative outcomes meant addressing the patient’s medical, psychological, pharmacological, social, environmental and functional needs.
Unfortunately, in much of the country, payment models do not properly incentivize organized systems of care to make the considerable investments in time and resources required to properly address patients’ social determinants of health. Purchasers would be wise to start measuring the degree to which social determinants of health are assessed and managed by different providers in their network. Those that are effectively managing their patients’ needs beyond merely their medical issues should be rewarded with enhanced reimbursement and steerage.
Providers should begin incorporating social determinants of health into their overall assessment of a patient’s ability to manage their illness burden. When a higher risk patient’s illness burden exceed their ability to manage that burden, extra care management resources should be brought to bear as well as any available community resources that can begin to address any of the identified issues.
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