Unlocking the Potential of Social Drivers of Health Data

By Kimberly Streett , RN, MSN?

Director, Quality Programs, NQF?

Our health is affected by factors beyond the confines of clinical settings. Where we live, employment status, education level, access to transportation, and other non-medical elements all influence our health. Recognizing, understanding, and addressing the profound impact of these external factors known as Social Drivers of Health (SDOH) on individual wellbeing is crucial to deliver high quality, comprehensive care that leads to better health outcomes. This is particularly important for many marginalized and historically underserved communities.?

Like many of my colleagues, in my career as a Registered Nurse, I have helped patients arrange reliable transportation to their doctor appointments, obtain stable housing, and connect with many resources to address the social needs impacting their health. This kind of work happens every day in a multitude of care settings, and I can tell you from experience, it is no small task to coordinate across multiple resources and networks for a single patient, let alone multiple patients.???

Imagine a healthcare system that seamlessly and efficiently addresses patients' health-related social needs through the integration of data and resources. But where do we even start???

In my role with the National Quality Forum (NQF), I have spent much of the past two years working with NQF’s Leadership Consortium , a multistakeholder group of experts and advocates from across the healthcare ecosystem, to explore how to leverage SDOH data to effectively address social needs, ultimately leading to improved health outcomes and increased health equity. In early 2024, NQF will release the Consortium’s final recommendations, along with lessons learned and promising practices gleaned from projects implemented in real-world healthcare settings by Consortium members.

Unlocking the potential of this data requires clarifying roles across care teams, establishing common data standards, and facilitating the continual flow of information to and from multiple stakeholders.

In 2022, Consortium members began looking at opportunities to make the greatest impact through SDOH data utilization and decided to focus on connecting patients and their families to resources and networks in their communities. The Consortium’s preliminary recommendations focused on building strong, sustainable relationships with community organizations, using technology to make connections more efficiently, and partnering with experts to leverage available technology. Establishing and strengthening relationships with community-based organizations and care providers can create referral systems and regular communication feedback loops. Digital platforms can be leveraged to augment referral networks and streamline referral processes with the help of experts in healthcare IT, digital platforms, and artificial intelligence.?

Patients are routinely screened about their health and daily lives, which generates a huge amount of data. Some of that data pertains to their day-to-day challenges and can help identify social needs that, if addressed, could lead to better health. Every community is different, but nearly all have organizations that exist to help people with social needs. Unfortunately, all too often there is a disconnect between local healthcare systems and providers, and local resources.?

Utilizing SDOH data across different entities is like orchestrating a complex symphony. Unlocking the potential of this data requires clarifying roles across care teams, establishing common data standards, and facilitating the continual flow of information to and from multiple stakeholders. In addition to unlocking the potential to improve individual patients’ health outcomes, SDOH data can be leveraged to expand the focus of health improvement efforts beyond individuals to address health disparities across entire populations.?

The Leadership Consortium’s recommendations are currently being updated based on the results of the real-world projects that are underway. Consortium members’ have shared their experiences and the many challenges integrating SDOH data into the day-to-day routine of healthcare, fostering patient trust to assist with social needs, and forming partnerships with community referral sources and other networks.??

Making SDOH information actionable requires more than merely acknowledging that health outcomes are deeply intertwined with the social fabric of our lives. It requires collecting SDOH data in a standardized format, sharing the data in meaningful ways, and connecting patients with resources they need to improve their health outcomes. On behalf of the NQF team, we are excited by the collaboration and success stories we have heard over the past two years and look forward to sharing more about these practical initiatives to advance efforts to improve the health of our patients and communities.?