Collaboration is Key to Address Social Determinants of Health

Developing partnerships with faith-based entities and CBOs can be vital in addressing historic health disparities among underserved communities.

If the COVID-19 pandemic has made one thing clear, it’s that people of color face significant health disparities, and experience the healthcare system differently than their white peers.

These disparities have only magnified the importance of health data collection strategies, standards, and the effective use of technologies. The virus’s disproportionate toll on minority and low-income communities, and the unprecedented economic devastation resulting from pandemic containment strategies, make clear the value and use of social determinants of health (SDoH) data. With COVID-19, clinicians see the intersection of SDoH and health status daily.

Some believe that integrating into patient-centered medical homes or a “medical neighborhood” would help reduce these disparities, improve health, and help these communities sustain healthier outcomes. However, for most community members, particularly those in underserved communities, a “medical neighborhood” can appear to be a diverse quilt of physicians, hospital systems, city and county resources, and neighborhood clinics with little or no coordination between them, leaving patients and their families to navigate such a system on their own.

Faith and community-based organizations (CBOs) have a historical and proven record of successfully accessing and engaging communities of color. This trusted access is critical to meaningfully combat the pervasive disparities in health and healthcare that can lead to negative outcomes for racial and ethnic minorities – many of whom have had a history of trust issues, such as with the monstrous Tuskegee Experiment. These disparities can persist regardless of education and socio-economic status. Because faith-based organizations typically have a central, influential, and trusted position, they are ideal neighbors to befriend in the medical neighborhood to address the SDoH.

Most patients and their families have little understanding of how their primary care practices coordinate (if at all) with other clinicians, pharmacists, city and county resources, faith-based and community organizations, transportation resources, and other institutions in the neighborhood –  meaning many often may assume that the system is much more organized and coordinated than it actually is.

Many of the goals of a high-functioning medical neighborhood will rely on sustainable broadband availability, coupled with culturally appropriate technology and greater health literacy to improve communication and coordination between and across healthcare insurers, providers, academic institutions, CBOs, and patients. In other words, patients would benefit from a medical neighborhood that:

• Encourages and drives the flow of culturally appropriate information across healthcare stakeholders, social service agencies, and patients;
• Uses technology and offline resources to ensure that clinicians and social service agencies readily participate in health information exchange; and
• Fully engages patients, particularly underserved patients, who are disproportionately impacted by health disparities.

The proper development, integration, collaboration, quality control, and deployment of culturally appropriate health and wellness technology and communication tools will result in improved patient access, engagement, and activation.

Addressing the SDoH and improving diversity, equity, and inclusion (DEI) is currently receiving an unprecedented level of positive attention by the healthcare and life sciences community. This focus and its collective energy are significant, especially after so many years of poorly addressed disparities in healthcare, disproportionately impacting underserved communities of color.

That’s why health technology companies, key industry groups, and standard-making organizations are now leading the charge:

• The Gravity Project, an HL7 FHIR Accelerator, is a key exemplar for the role of standards and technology in health equity, which includes recommendations for ways to address food insecurity, housing instability, homelessness, and other domains of the SDoH via capturing and exchanging data.

• The Alliance for Innovation on Maternal Health – Community Care Initiative (AIM CCI) is a federally funded project focused on improving maternal health outcomes through the use of Maternal Safety Bundles in non-hospital settings. AIM CCI is partnering with community organizations in areas with high maternal mortality and morbidity, and has active projects in six cities across the nation.

• The Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion: The Division for Reproductive Health (DRH) has developed programs to improve women’s health, improve pregnancy health and care, and provide infants the healthiest possible start in life. Multiple surveillance systems and activities in DRH provide information and data that help scientists and health professionals understand how to deliver the best care.
• The National Institutes of Health (NIH): The Community Engagement Alliance Leadership (CEAL) encompasses a diverse ecosystem of partners and trusted leaders engaging in and working with communities across the country to address disparities, mental health, and research as they pertain to the SDoH-related challenges of community health workers.

Also, the terminologies and technologies supported by standards organizations and related industry groups, like WEDI & HIMSS, can help improve effective information capture and exchange. Also, other HL7 Workgroups (like Public Health, Health and Human Services) and IHE-USA focus on maternal/child health will greatly expand the healthcare sector’s ability to effectively care for the full needs of individuals and communities.

For insurers, tackling the challenge of health equity and reducing health disparities is a priority. In April 2021, as part of its ongoing mission to improve the health of America, the Blue Cross Blue Shield Association (BCBSA) announced its National Health Equity Strategy to confront the nation’s crisis in racial health disparities.

The BCBSA Health Equity Strategy was preceded in 2018 by the Blue Cross Blue Shield Institute^SM, created to address the social and environmental factors that greatly influence health and health outcomes. Several of the payer sponsors of the Gravity Project have a comparable commitment to health equity:

• In 2020, Highmark announced its participation and commitment in support of the aforementioned Gravity Project.

• In 2021, Humana Inc. announced that its veteran population is the latest addition to its Bold Goal strategy to improve the health of the communities it serves.

• In 2019, UnitedHealthcare announced a collaboration with the American Medical Association (AMA) to better identify and address the SDoH to improve access to care and patient outcomes.

There are a variety of stakeholders in the healthcare industry working together to address health equity. We can meaningfully address health disparities for communities of color if the industry works together to better collect, exchange, and analyze data on food insecurity, housing instability, transportation access issues, and other similar barriers to better health.