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How social determinants of health can enable value-based care

May 07, 2021
Health IT

The overarching solution is called Value-based Benefits Administration, or VBBA, which is about leveraging SDOH to implement value-based care. VBBA requires two components.

One is the value-based care itself. This could be episodic in nature, or it could include chronic disease management or population health initiatives, with individualization based upon risk stratification or other data.

The second component would be social and community factors. A community care network includes 1) traditional healthcare providers, and 2) social services and community-based organizations.

Coordinating them is essential to achieving VBC.

Each of the two components of VBBA – episodic care and social/community – requires technology to operate. The platform for episodic administration, for example, would handle things such as bundled payments and care for chronic conditions, while the social/community one would coordinate SDOH data sharing and communication.

The healthcare industry does a lot of things right, but it has struggled to influence the social conditions, behaviors, and daily activities occurring outside medical facilities that directly impact the health and well-being of patients and plan members. By integrating the episodic care and SDOH platforms, providers and payers have both a comprehensive view of the individual and resources that allow them to impact behaviors at the street level.

In practice this means a medical professional can know whether a patient with medical and social needs received education on her diet or behavioral services from a community organization. Having this data not only improves care coordination, but also offers context and information for healthcare organizations and practitioners to reimburse or incentivize those community-based service providers.

Patients also have a role and a stake in VBC, so it is important that they are integrated into what traditionally have been B2B processes. Providing more visibility and transparency for the patient empowers them with knowledge about their conditions and what they can do to impact their outcomes. This, too, is a way to impact behavior at the street level.

Digitization of data at the edge facilitates a more holistic view of the patient. But one needs to access and convert that data using tools such as longitudinal health records (LHR) processing across different data sets for the patients, natural language processing for digitization of unstructured and semi-structured data, and language translation for non-English speaking populations. Many caregivers and in-home caregivers speak English as a second language, so getting accurate information from them about patients in their care taking medications and following prescribed protocols is imperative. In some cases, miscommunication can be fatal.

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