While social determinants of health (SDOH) have been a topic of much discussion and a driver toward understanding and furthering health equity, definitions and approaches vary across the healthcare spectrum.
Health plans and healthcare organizations are being asked to collect and integrate health equity data from multiple sources and then analyze that data across determinants to identify subpopulations who are experiencing disparate outcomes. Additionally, plans are asked to then identify the key drivers of the barriers to create meaningful interventions and collaborative partnerships with community-based organizations and/or population health vendors to address and solve the issues.
With this shift, the HMA Quality and Accreditation team remains vigilant in staying ahead of these changes to provide programs, services, and care models that align with, and provide, health equity.
Through the lens of Quality improvement, our experts weigh in on how multicultural accreditation, SDOH, and other tools lead to programs and policies better suited to creating an equitable healthcare system for all.
Nicki Bongiovanni, RN, BSN – An experienced nurse and quality improvement leader, Nicki is focused on driving healthcare quality using data and evidence-based best practices. She is a health plan accreditation expert and specializes in the population health management and case management requirements including complex case management.
Anthony Davis, MPH – Dynamic and strategic, Anthony leads the HMA Quality and Accreditation Services team. He has designed quality, regulatory, and strategic intervention programs for compliance and accreditation at all levels and across the healthcare spectrum.
Isis Montalvo, MBA, MS, RN, CPHQ – An outcomes-driven nurse and executive leader, Isis has been focused on patient-centered quality care throughout her career. In addition to her clinical delivery systems and health plan experiences, she previously served as director of the National Center for Nursing Quality at the American Nurses Association and successfully led the strategic growth of its nursing quality database.
Sarah M. Owens– Focused on Medicare and the Stars ratings that surround it, Sarah is an expert in managed accountable care and operations bridging health plans and providers as providing a more complete system of care.
David Wedemeyer, RN, BSN – A data expert and experienced HEDIS developer, David focuses on quality improvement, including developing models of care. A registered nurse, he also has patient care experience as well as supervisory experience with nursing teams.
What are the most pressing issues you see impacting quality as the focus shifts to understanding and incorporating SDOH?
- Nicki Bongiovanni – It is essential that health plans and other healthcare organizations have the ability to measure outcomes across determinants of health, including race, gender, urban vs. rural and more, so they have a deeper understanding of the barriers to accessing care.
- Sarah Owens – Safe, affordable housing and food security will be key, especially for the elderly, people with disabilities, including those suffering from serious and persistent mental illness, people with a substance use disorders, as well as marginalized populations such as those formerly incarcerated. Also, recognizing the impact the COVID-19 pandemic and resulting social isolation have had on increased substance use and for which the CDC has published guidance to direct those in need to resources.
- Anthony Davis – SDOH and health equity data is a hot topic within the healthcare industry, but unfortunately, there have been limited inroads made into developing a model for true health equity and quality. There is a significant absence of data looking at the impact quality and health equity have together, but this is beginning to change with the incorporation of health equity measures into value-based care programs and in Medicaid requests for proposals (RFPs). The “same old” response to SDOH is no longer sufficient to win new business. It is clear that we are only scratching the surface on factors such as race, language, and ethnicity stratifications as well as the use of Z-Codes in quality performance measurement.
- David Wedemeyer – Health plans need to be prepared to collect SDOH-related data about their members, as well as to identify interventions, related outreach, and value-based incentives for providers to remove barriers to addressing SDOH.
How should healthcare providers, plans, and states position themselves for success incorporating SDOH?
- Sarah Owens – States may expect more from the health plans and providers, especially those they fund or coordinate with through Medicaid. This includes child and family health programs, managed long-term services and supports (LTSS) and Dual-Eligible Special Needs Plans (D-SNP). Plans should be collecting race, language, and ethnicity data. In addition, they will need to assess members, either directly or through their providers, including those who are difficult to reach, to collect SDOH information, tracking care, and to connect those in need to available resources.
- Anthony Davis – Addressing SDOH requires a new approach to quality improvement, being more reliant on measures, including, Z-Codes, and incorporating race, language, and ethnicity data. This will require collaborative inroads to be made on a state-by-state basis to truly impact quality scores from a social determinant’s perspective. State Medicaid agencies should be looking to encourage managed care organizations (MCO) and providers to conduct more data sharing agreements with one another and helping to centralize critical clinical information needed for measurement. Similarly, health plans and providers should be focusing on their member stratification data and start incentivizing for the use of new codes to capture information that is needed for measuring health equity performance.
- David Wedemeyer – Providers, plans and states should begin to develop value-based incentives to encourage providers to do assessments that include SDOH data collection. Plans will also need to build or link to customized resource platforms to identify services or resources for their patients.
- Isis Montalvo – Health plans can partner with community organizations that can provide SDOH-respective services with cultural considerations. This will facilitate more trust and engagement with members.
What is the role of quality in addressing SDOH?
- Nicki Bongiovanni – Quality is at the center of the improvement strategies and initiatives that are implemented to address SDOH and ultimately improve outcomes. Quality improvement is a team-based approach and requires commitment and buy-in across all departments at an organization. An organization that embeds quality in its culture and day-to-day operations will be successful in overcoming barriers and improving quality.
- Sarah Owens – The fact that NCQA has pivoted to an SDOH accreditation underscores the significance of the role of quality. Population Health Management begins with an assessment of the individuals targeted for enrollment and then those enrolled. Managed care has long had a mandate to look at population health while delivering an individualized patient centric focus. It is impossible to truly assess health without looking at social determinants.
- David Wedemeyer – Quality has a central role in SDOH measurement and correlating this to other quality measures and outcomes. This includes measuring SDOH by race, ethnicity, language and/or geographic areas so the plan can customize their actions to meet specific needs of a subpopulation.
- Isis Montalvo – Quality improvement departments can support the analysis of data collected to provide a Population Health Assessment, and then partner with other departments to address needs holistically and identify additional targeted approaches for overall needed interventions.
How can SDOH be implemented into current practices?
- Sarah Owens – Providers and plans need to begin by assessing their patients/members for measures outside of the traditional medical model. Asking questions about housing, socialization, eating patterns, and access to food are all critical. This is not a static state and therefore these measures need to be reassessed regularly, at a minimum once a year.
- David Wedemeyer – SDOH collection could be improved with greater provider involvement, and this could include incentives for the collection and reporting.
- Isis Montalvo – Z-Codes can be used to identify factors influencing health and are part of ICD-10 codes. Gathering this information in aggregate can help the provider and health plans better identify the needs of their patients or members so that a strategy can be designed to address those needs. Further adoption of Z-Codes and coding can facilitate capturing this valuable data resource.
What should health plans and/or provider groups be doing and thinking about when reporting quality improvement scores in relation to SDOH?
- Sarah Owens – The point of measuring is to identify need, introduce interventions, and then evaluate those actions to assess whether the actions are improving health status. Comprehensive assessments, identification, and coordination of community resources is at the heart of population health management.
- David Wedemeyer – Groups must be able to separate SDOH metrics to measure completeness of data, as well as the outcome measures to show the impact of interventions by sub-populations.
What are the most important data elements when creating a health equity or SDOH framework?
- Isis Montalvo – The Office of Disease Prevention and Health Promotion, a division of the U.S. Department of Health and Human Services has written that SDOH can be grouped into five domains: 1) Economic Stability, 2) Education Access and Quality, 3) Health Care Access and Quality, 4) Neighborhood and Built Environment, and 5) Social and Community Context.
People’s health, wellbeing and quality of life can be impacted significantly by addressing SDOH. A couple of data element examples include understanding whether the member has safe housing, transportation, or access to nutritious foods. Are they in a safe environment? There are multiple data elements that could be captured along with evaluating the demographics of the population being served. This information would then serve as the basis to structure support and address their needs.
With changes coming to HEDIS measures, how should health plans and providers be positioning themselves with race, language, and ethnicity stratifications.
- Sarah Owens – The first step is uniform collection. The second is to look at the variations in SDOH between enrolled groups along the race, language, and ethnicity lines. This will help plan evaluate variations and consider how to deploy interventions to obtain better health outcomes. This will be critical to the plan’s ability to improve HEDIS measures.
- David Wedemeyer – Plans and providers should be prepared to improve their direct method of capturing and collecting SDOH demographic data to apply this to their HEDIS data.
As multicultural health accreditation shifts to health equity standards and SDOH, how can providers and health plans address the evolving needs of accreditation?
- Nicki Bongiovanni – There needs to be a deliberate decision to shift focus across the organization. Providers and health plans should think of the shift as a journey. Start by building a foundation for advancing health equity across the organization by aligning quality improvement and health equity initiatives (i.e. CLAS) with NCQA’s Multicultural Health Care Distinction (MHCD).
- David Wedemeyer – Understanding the population is critical to the process, but collecting, storing, and then integrating the data is a challenge. Plans and providers need to evaluate their current processes and look for opportunities to collect and utilize this data to improve patient outcomes.
What are best practices to incorporate health equity into quality frameworks?
- David Wedemeyer – The best practice is collecting and verifying SDOH data and incorporating findings into current practices. Once this is done, outreach can be targeted on the basis of these findings, and health outcomes can be tied back to specific SDOH challenges.
- Isis Montalvo – Given that SDOH contributes to health disparities and health inequity, incorporating a health equity lens is essential to improve quality of care. Best practices include understanding any barriers to care based upon SDOH, addressing the barriers, and further analyzing care and barriers with a health equity lens to try to improve quality for all.
What are state Medicaid agencies and the Centers for Medicare & Medicaid Services (CMS) looking for from providers and plans to deliver on when it comes to health equity?
- Anthony Davis – States are starting to look for plans that have a proven process for addressing health equity within their populations or at least a plan to quantify the impact that addressing health equity has on quality, cost, and utilization. We often see plans and provider groups that list all the things they do, including community engagement programs, housing funding, food insecurity programs, and more. While these programs speak to specific SDOH issues, they are only microcosms of a much broader concept of addressing the unique needs of each member from a health, social, and cultural standpoint. Simply listing these types of programs is no longer hitting the mark with CMS and state Medicaid agencies. State and federal agencies are now starting to look for more quantifiable data on the impact and wanting to understand how providers and health plans are building their models and what makes them impactful.
- David Wedemeyer – CMS and Medicaid agencies are looking for plans and providers to show they are assessing, collecting, and analyzing this data to identify opportunities to provide, or link to, appropriate resources and to measure outcomes.
- Isis Montalvo – Plans should be creating a population health framework which assesses SDOH needs, evaluates health equity in delivery of services, and implements strategies to address population and individual needs.
Are there specific trends in health equity and value-based trends within state Medicaid and federal Medicare agencies?
- Anthony Davis – We are seeing many more states attach a large number of points to health equity considerations in their RFPs. In the past year, we have seen at least three managed Medicaid RFPs with specific sections and points tied to health equity and SDOH either incorporated into their quality sections or care management areas. Additionally, we have noted several states, such as Pennsylvania, where capitation revenue, tied to quality performance measures, is starting to be linked to the alleviation of healthcare disparities between populations. This often involves removing disparities that exist between races for preventative services like prenatal/postpartum care, blood pressure control, and diabetic A1C monitoring. We expect that the small handful of states that have adopted these practices will not be the only states to do so, and with more emphasis being put on pilot projects within Medicaid and Medicare entities, we can expect to see these types of programs enter more spaces over the next two to three years.
- David Wedemeyer – The current trend, while varying state-to-state, is a push toward collecting the metrics. If a plan has not done any planning and/or work toward incorporating health equity and value-based trends into their organization, they are behind. At this point, plans should already have the basic foundation or structure of how they will be capturing this data and the process for determining how to use it.
Learn more about HMA’s Quality and Accreditation services and how we can help make sense of changes to quality measures to maximize value-based contracts, win requests for proposals, increase membership, and optimize member experience.