Montefiore in the News

In a March 2019 interview with Healthcare IT News, Dr. Jacob Reider – CEO of the Alliance for Better Health and former deputy national coordinator for health IT – described the conversations he'd been having about social determinants of health with an array of different healthcare stakeholders.

"There's a lot of interest in this in this domain," he said. "Folks from federally-qualified health centers, so on the frontlines of the medical side. We had folks from states, and/or or former state leaders who are looking at this from a public health perspective. We had folks from social care providers. We had health plans. So we had this really broad cross section of the care continuum, all saying, 'Hey this is important and we would like to participate in some way, in figuring this out together.'"

The push to do a better job incorporating social determinant information into care and treatment plans gained momentum in 2019, as more and more provider organizations recognized the key role that housing, transportation, food security and other non-clinical factors play in patients' health.

If the value of addressing such variables is apparent, so too is the challenge many health systems face integrating SDOH into workflows, starting with the electronic health record.

"The first step is, how are we capturing information about identification of people's social care needs," said Reider. "Because in the medical universe we had ICD, and SNOMED-CT that we would use to capture information. I'm not saying we did it super well, but we had a reasonably good way of representing the fact that a patient had diabetes, using a certain coding system.

"We don't have a very good consistent, predictable, repeatable mechanism for expressing that somebody has food insecurity needs," he said. "Or is a domestic violence victim. Or has a behavior health challenge that makes it difficult to leave the house. Or that they have transportation challenges."

Still, said Reider, "people are starting to think about this in a way that I don't think they had been together before. There have been isolated instances of these conversations, but I don't think they've come together before."

As the year went on, there was more and more evidence to back up that idea – that cross-stakeholder efforts to pay more attention to SDOH were reaching critical mass. Among the many stories Healthcare IT News – and our sister publications, Healthcare Finance and MobiHealthNews – reported in 2019, the progress was evident:

• Reider's own Healthy Alliance Independent Practice Association, which bills itself as the first such organization focused exclusively on addressing social determinants, launched an innovative collaboration with a regional not-for-profit insurer, MVP Health. The initiative will give community based organizations in the Albany, New York, area funding and technology access to better coordinate health and wellness services.
• A major report from The National Academies of Sciences, Engineering, and Medicine made the case that SDOH data needs to be integrated more systematically into healthcare delivery, and that providers should make organizational commitments to addressing these factors – and offered some valuable recommendations for how to do it.
• We explored how SDOH initiatives are influencing the next wave of health tech startups, with more and more new tech companies "focused on tackling the issues related to matching patients with the existing maze of social services, which is an extremely fragmented ecosystem."
• We showed how more inclusive EHRs can help extend a more welcome patient experience and even save the lives of transgender patients, with providers such as Massachusetts General Hospital adding sexual orientation and gender identity information to its clinical systems.
• The American Medical Association and UnitedHealthcare teamed up on new billing codes that address social determinants, working together to standardize how data is collected, processed and integrated.
• Mount Sinai used artificial intelligence to help unlock social determinant data in the EHR; the natural language processing algorithm has helped the New York health system gain new insights from its unstructured notes, boosting its value-based care and population health efforts. 
• And another New York health system, Montefiore, has posted big savings by tackling the social determinants of health; by investing in housing for homeless patients, the hospital has dramatically lowered its ED visits and unnecessary hospitalizations – for an annual 300 percent return on investment.

Taken together, these innovations and success stories point to big changes ahead with regard to the ways healthcare care is delivered – and by whom.

"What we're seeing, which I think is fascinating, is that the team is is expanding beyond the practice, beyond the clinic," said Jacob Reider.

"We've seen the culture evolve to where the doc and the nurse and maybe there's a care manager there and that's new that they've all started working together," he explained. "And then they recognize, 'Gosh the food pantry is part of the team. The transportation of poor people, the housing coordinator, the social worker at the county Department of Public Health. These are all members of our team too. Wow.'"

Healthcare IT News is a publication of HIMSS Media.