The role of SDoH
Recurring and proactive contact with patients can help avert more serious health problems caused by delays in seeking care. It makes sense, then, that patient engagement initiatives are ongoing and part of a continuous care model. This is particularly relevant in primary care, where providers regularly reach out to patients with health-related advice and reminders about regular tests, routine visits, and medication adherence.
Providers can leverage patient engagement to identify external factors, or social determinants of health (SDoH) that affect individual and population outcomes. SDoH can uncover health equity-related situations and conditions that impact the ability of an individual to stay healthy. Examples include living in an unsafe neighborhood or lack of transportation. SDoH data can be used to target individuals with educational efforts or referrals to social service agencies and other community-based organizations.
For provider organizations to confidently and effectively take on responsibility for outcomes, they must identify populations in need of the most attention. VBC programs may incorporate patient outreach metrics for medication compliance, anticipated visits per year, and others.
Value to payers
Payers also can benefit through stratifying patients by risk level and PAM score. This information can be used to identify potential opportunities, such as carve-outs and other “pay for quality” programs that payers use to boost their bottom lines.
Having a more holistic view of the patient enables payers to play a greater role in care coordination, management, and patient engagement. Payers can see all the care team data for a patient, instead of bits and pieces. Sharing this information across the care continuum under a VBC program should result in better care management and a better patient experience.
Empowering the patient
People shouldn’t have to struggle to obtain their health data; it should be as easy as a handful of clicks on a computer screen or mobile app. The challenge for providers and payers is that not all the data standards necessary to support robust patient engagement initiatives exist.