National Health Center Week (NHCW) is an annual time to celebrate the nation’s health centers which serve as health homes to over 28 million otherwise underserved patients. Health centers are incubi for innovations to serve the whole patient including their social determinants of health (SDOH). For NHCW, August 4-10, 2019, every day has a different theme within which we can honor the health centers that are rooted in the communities they serve – within and outside of the clinic walls.

Today, Sunday, August 4, the theme is Social Determinants. SDOH have been shown to have a larger impact on personal health than medical care, genetics and health behaviors. Growing awareness of the impact of SDOH has led to calls by federal agencies to include SDOH in health care decision-making and payment as well as patient risk stratification. The National Academy of Medicine included 17 social and behavioral domains of SDOH data (“neighborhood” data is the only domain that is not individual-level data) to capture in EHRs as a part of Meaningful Use, and many organizations have developed tools to help organizations capture those data. Other organizations, like HealthLandscape, use data from secondary sources which tell us a lot about the neighborhood where a person lives, therefore already filling in much of the picture without needing to capture data on all 16 individual-level domains, or adding to the picture in other cases.

But the question remains – what do we do with these data once they are captured and added to the EHR? Who needs those data? What will they look like? How do we integrate them with clinical data? Most solutions are still focused on the individual patient – connecting patients to resources and providing referrals – but what about the population health targets like payment reformation and patient-risk stratification? HealthLandscape is working on these and other questions related to the addition of these data to EHRs. In our Community Vital Signs suite of tools we have many different visualizations of patient data – both clinical and community data – so we can test and improve the inclusion of SDOH in health care to improve population health. Visit our Population Health Profiler to see one example of these tools.

In the meantime, our other mapping tools like the UDS Mapper and others allow you to quickly visualize (without full EHR integration) how SDOH affect communities. Within the UDS Mapper we provide ZIP Code-level SDOH. Users can explore their communities and see where there are pockets of need, identify areas for growth, and plan to meet community needs. Health centers have always been rooted in communities, and the UDS Mapper is the tool that helps visualize need in those communities.


If you have questions, or would like assistance with any of the HealthLandscape tools mentioned above, please contact us anytime. 




Jennifer Rankin
Senior Manager, Research and Product Services
HealthLandscape

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