Building more effective health systems through social determinants and patient-centered approaches

Laura-Copeland-Final_600The healthcare landscape is undergoing a significant shift. As we move toward a value-based model, the focus is intensifying on patient-centered care, with improved outcomes and population health taking center stage. To fully deliver safe, effective, timely, efficient, and equitable care that enables people to take responsibility for their health and well-being, we must tackle health disparities and inequities tied to social determinants of health (SDOH). These include:

  • Lack of safe housing, transportation, and neighborhoods.
  • Racism, discrimination, and violence.
  • Barriers to education, job opportunities, and income.
  • Limited access to nutritious foods and physical activity opportunities.
  • Polluted air and water.
  • Gaps in language and literacy skills.

Data-driven insights and innovative technologies can help providers make meaningful advances in developing relationships with the individuals and communities they serve. By harnessing these powerful tools, healthcare providers can gain crucial information about patient populations and develop community-based strategies to identify and address risk factors before they lead to chronic illness. Community health teams, also known as care networks, can help connect clinical care and a person’s daily lifestyle to meet complex needs across providers, settings, and systems of care. This approach uses community partnerships and local resources to enhance care coordination and promote whole-person healthcare. Vermont Blueprint for Health and Community Care of North Carolina are two examples of how community health teams can empower patients, advance healthier populations, and improve financial sustainability for hospitals and health systems.

Using data for targeted interventions

SDOH have a significant impact on patient outcomes, with most of our health decided by what goes on outside the four walls of the hospital. Consider Indigenous peoples, who face significant socioeconomic disparities that lead to disproportionately higher rates of diabetes, heart disease, tuberculosis, maternal and infant mortality, malnutrition, and more. In Canada, the gap in life expectancy between Indigenous and non-Indigenous people is 17 years.  

Addressing these issues requires understanding and responding to unique cultural needs. A patient-centered approach must go beyond clinical care to drive systemic changes that dismantle historical injustices, reduce barriers, and support community revitalization and empowerment efforts. Electronic health records (EHRs) and community partnerships can help clinicians collect and analyze SDOH data and identify patients facing social risk factors. This data allows for patient stratification, helping providers to prioritize resources and tailor interventions to address specific needs, such as:

By addressing upstream social determinants and elevating cultural competence, you'll improve patient well-being and potentially reduce costly hospital readmissions, leading to a win-win for patients and healthcare organizations.

A holistic approach through data integration

Disparate data and information systems can prevent clinicians from getting a complete picture of a patient’s health. A diabetic patient might struggle to manage their condition due to food insecurity, a person who does not speak English may have difficulty communicating with their care team, and someone who belongs to a racial or ethnic minority group might be dealing with stress related to the psychological toll of racism. By integrating clinical data with SDOH, we can create a comprehensive patient profile that provides a 360-degree view of the individual. Additionally, pulling in data from wearable health trackers allows for remote monitoring of relevant metrics like heart rate, activity levels, menstrual cycles, sleep patterns, and more. Armed with this knowledge, clinicians can personalize care plans to address the illness and the underlying factors influencing it.

In an ideal world, a diabetic patient’s medical recommendations would be coupled with referrals to food assistance programs, a non-English speaking patient would be supported through culturally appropriate care teams and treatments, and medical professionals would be part of the charge to end racist policies and institutions while also helping patients better manage the emotional and physical effects of racial trauma. Data integration empowers patients, providers, and organizations by helping to lower costs and improve engagement, care quality, and health outcomes.

Using data analytics to predict and prevent

A growing understanding of the power of data analytics to help clinicians get ahead of potential health conditions by addressing risk factors is driving the transition from a reactive, disease-centric healthcare model to a proactive, preventative one. Advanced data analytics can mine EHRs and genetic information to pinpoint individuals most susceptible to specific health conditions. Early detection through data-driven preventative screenings and interventions can result in better patient outcomes, reduced lengths of stay, and lower healthcare costs. By embracing proactive care fueled by data, healthcare organizations can build a future where prevention is the cornerstone of a healthier population and a more viable healthcare system.

Building a more patient-centered future

The future of healthcare is undeniably patient-centered. We can use data and health IT to help clinicians address the illness and the whole person – their social determinants of health, unique needs, and potential for proactive well-being. Achieving this vision requires creating healthy environments inside health systems and throughout communities that allow individuals to live well and take control of improving their health.

With access to more health data than ever before and innovative tools to make this valuable information more accessible and usable, we have an opportunity to strengthen the provider-patient relationship, build trust and transparency in the healthcare system, and create a more sustainable future for patients, clinicians, and organizations.

Hear more from Dr. Laura Copeland:


Topics: featured, Patient-Centered Care

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