Healthcare is nuanced. Professionals in this field learn early that effective provision of healthcare requires a deep understanding of the communities in which they work. As the daughter of two pharmacists, I witnessed the positive impact of personalized care in communities. I inherited my parents’ dedication to understand and support their patients, and I’ve carried on this commitment as a pharmacist myself. I became interested in the factors that impact health outcomes and access to quality healthcare, which led me to evaluate the community pharmacist role in understanding social determinants of health.
Defining social determinants of health
To understand the important role that pharmacists can play here, we must first define SDOH. Social determinants of health (SDOH) are the environmental and social circumstances that shape health outcomes. According to the Centers for Disease Control and Prevention (CDC), SDOH are “conditions in the places people live, work, play, and worship that affect their health.” Factors outside the healthcare system affect a person’s health outcomes, like economic stability, education and access to food. The COVID-19 pandemic exacerbated economic inequalities and social isolation. Understanding the SDOH framework can aid healthcare workers in recognizing the effects of social and environmental factors on health outcomes. Because SDOH factors are unique to individuals, collecting and aggregating data is the first step in tackling unmet needs. To address gaps that negatively impact patients’ health, healthcare payers can rely on the robust pharmacist network with Outcomes.
Understanding the 5 domains of SDOH
Healthy People 2020 is an initiative that defines five domains of social determinants of health:
- Economic stability
Financial resources and socioeconomic status can be linked to health outcomes because of the impacts on a person’s access to food, housing and healthcare. For example, if someone needs to choose between affording food or a prescription, depending on the importance of the medication, a person may be forced to forgo the medication that month. - Education access
Education can be linked to improved health outcomes and wellbeing. One’s education level also impacts their understanding of basic health information. Health literacy empowers individuals to properly care for themselves. - Healthcare access and quality
Being uninsured is a major health risk. However, even if an individual is insured, they can still experience barriers to healthcare. For example, is there reliable transportation? If someone cannot physically get to a pharmacy for their prescription, it’s not feasible to receive the healthcare they need. - Neighborhood and built environment
The environmental conditions in which one lives play a big role in their access to proper healthcare. Are there any pharmacies within 20 miles? Do they have access to healthy food? Food and healthcare deserts impact the ability to seek necessary care. - Social and community context
Having a strong social network, whether it be friends, family or coworkers, is critical for mental health. If an individual is living in isolation or doesn’t have many connections, their health and wellbeing can suffer.
Connecting healthcare providers for better patient outcomes
Outcomes Empowers Pharmacists to Address Social Determinants of Health
There is growing appreciation for the influence factors outside an individual's traditional medical profile have on their overall health and well-being. These non-clinical factors, termed social determinants of health (SDOH), include things like access to healthcare, income, education, housing and food security.
Understanding and addressing SDOH is critical for improving the health and well-being of both individuals and communities. Healthcare organizations, payers and quality measurement organizations have begun to incorporate social needs into the way care is delivered. Addressing SDOH is one component to CMS's larger strategy of tackling health equity within the healthcare system.
One of the most recent ways healthcare has changed to incorporate social needs into its delivery is the release of the 2023 Healthcare Effectiveness Data and Information Set (HEDIS) measure, "Social Needs Screening and Intervention." In this article, we'll look more closely at how SDOH is measured through HEDIS and how Outcomes®, through an innovative partnership, can unleash the power of community pharmacists to meet the challenge.
NCQA will focus on social needs with future HEDIS measures
HEDIS is a set of standardized measures, developed and maintained by the National Committee for Quality Assurance (NCQA), used to compare the performance of different health plans. One of the newest measures, effective in 2023, is the Social Need Screening and Intervention (SNS), which aims to identify and address social needs that may impact an individual's health and healthcare utilization. With a focus on food, housing and transportation, this measure will evaluate health plan's ability to both complete social needs assessments for plan members, and intervene within 30 days of identifying social needs gaps.
The Centers for Medicare and Medicaid Services (CMS) proposed incorporating this new HEDIS measure into the Star Ratings programs for Medicare plans. This would further emphasize the importance of SDOH and force Medicare plans to consider new strategies for delivering SDOH assessments and interventions. Extending beyond food, housing and transportation in the SNS-E measure, NCQA intends to focus on social isolation, loneliness and social support for measure year 2024.
Community pharmacists are vital to addressing social needs
Payers will need a multi-pronged strategy to effectively screen all members on food, housing and transportation needs. Even more cumbersome is executing strategies to close social need gaps when identified. Given the magnitude of effort required to reach and engage with all members, payers will need to consider all methods and channels of outreach, including the incorporation of pharmacists as a part of the strategy.
Nearly 90% of Americans live within five miles of a community pharmacy, and pharmacists rank fourth among America's most trusted professions. It's been shown that patients visit pharmacies between 1.5 and 10 times more often than primary care, and there are over 66,000 pharmacies nationwide. Because of this, pharmacists are in a unique position to help payers effectively scale their programs to reach more members and address barriers to social needs.
Outcomes has facilitated community pharmacy-led SDOH screening as a part of a pilot in 2019. This wide-scale pilot engaged 2,200 pharmacies in delivering around 10,000 SDOH assessments and demonstrated an average $1,500 reduction in medical savings for members screened. One of the biggest challenges for pharmacists was in identifying community-based organizations and other resources that can help close members' social need gaps.
Outcomes empowers pharmacists
With this challenge in mind, Outcomes has partnered with a digital health leader to develop a comprehensive screening and intervention program powered by the Outcomes platform. This partnership aims to overcome barriers in finding applicable local resources, by auto-generating a list based on the results of an SDOH screening and the patient's zip code.
The program works by incorporating screening and referral into the pharmacy workflow, as well as by leveraging the new partnership to provide tailored real-time interventions:
- Screening: The Outcomes platform prompts the pharmacist to engage a member in completing a social needs assessment. This questionnaire draws validated questions from the CMS sponsored Health-Related Social Needs Assessment tool to address food insecurity, housing instability and transportation needs.
- Documentation: Pharmacists document responses to assessment questions in the Outcomes platform, as well as, any action taken on social need gaps.
- Referral and Intervention: The digital health partner populates a real-time resource for pharmacists to share with members highlighting local resources available to address gaps in social needs, based on responses to the social needs assessment. The member walks away from the assessment with information in hand and referrals to organizations that can support them in a time of need. Additional follow up can be incorporated as well to close the loop on members' gaps in social needs.
Finally, health plans will be able to access member responses so they can tie that data into their existing social needs strategy, including sharing that data with their internal case managers for further follow up and referral.
Health Equity vs. SDOH - What’s the Difference?
Health equity and Social Determinants of Health (SDOH) have transitioned from industry buzzwords to weighty challenges we need to confront. A 2021 report from The Commonwealth Fund found inequity examples in every state in the U.S. including the District of Columbia. According to the findings, only six states had health systems that scored above the national average for all racial and ethnic groups studied, but even in those instances, large disparities were evident.
With CMS strategy, guidance and requirements continuing to emphasize the importance of addressing inequities in healthcare, all players in the industry are scrambling to figure out their role. In order to make an impact, the critical first step is understanding the definitions of the terminology and the relationship between “health equity” and “SDOH.”
The Centers for Disease Control and Prevention (CDC) defines Health Equity and SDOH
“Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities. Achieving health equity also requires addressing social determinants of health and health disparities.”
“Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”
How Health Equity and SDOH go hand in hand
Health equity is where every person has the opportunity to access health care services to reach their health goals. In a state of equitable healthcare, access and opportunity are not impacted by non-medical factors like race, ethnicity, income status, or other factors. In order to achieve this state, we need to understand which factors play into negative health outcomes. This is exactly where SDOH comes into play. SDOH represents factors in a patient’s environment, anything from access to food and housing to level of education and work stability. When these factors are negatively impacting one's life, it perpetuates barriers to health care access and thus leads to unfavorable health outcomes. SDOH factors are strongly tied to disparities within the health care system. Achieving health equity requires we learn more about the SDOH factors at play within the populations of patients we manage.
Our response to improving Health Equity
With the introduction of the Social Needs Screening and Intervention HEDIS measure (SNS-E), plans are not only pressured to administer SDOH assessments for all patients, but to also intervene when gaps in health-related social needs are identified. This is a monumental step forward in the pursuit of health equity. Careful assessment and follow-up will be key in leaving a lasting impact for members. SDOH screening creates another opportunity to meet members where they’re at, so we need to consider facilitating screening through common touch points – pharmacy visits, physician visits, in-home care, or lighter touch methods like text and email.
A heavy focus needs to be placed on how we act on the SDOH data collected through assessments. Be sure to avoid the trap of just collecting data. If you are collecting and evaluating data, you need to be prepared as an organization to take action on the findings. Consider partnerships with community-based organizations or aggregators of local services to connect patients with resources for their specific social need gaps.
SDOH Assessments and interventions drive progress towards health equity, this alone cannot be the only strategy. In all clinical programs we administer, we must ensure we are collecting data where we can and using that data to understand where there are disparities. SDOH is a perfect springboard to developing a more comprehensive solution.
Outcomes’ SDOH program is just one example of how we partner with plans to improve health outcomes for all members regardless of demographic. Formulating programs across commercial, Medicare and Medicaid audiences, Outcomes was built on the premise of caring for the whole patient and designs solutions to improve results. Our nationwide network of pharmacists coupled with multi-channel delivery and artificial intelligence allows us to bring the right interventions and education directly to members wherever they are, addressing SDOH, improving adherence, reducing overall health costs and increasing engagement with their pharmacists.
Leveraging the Outcomes network for meaningful connections
At Outcomes we believe in empowering connections between pharmacists and patients, so we’re adding a new patient consultation to our program that engages pharmacists and pharmacies to collect SDOH data and close gaps for patients. We know that pharmacists are the most accessible healthcare professionals and have the potential to make a lasting impact on patient outcomes.
Outcomes piloted an SDOH screening service in 2019, and results were published in the Social Determinants of Health Resource Guide (page 38) by the Pharmacy Quality Alliance (PQA). More than 9,800 screenings took place at 2,100 retail pharmacies over about two months. Patients who had completed an SDOH screening with the pharmacy showed an average of $1,500 in decreased medical spending. This pilot demonstrates the positive impact a pharmacist can have on patients in their community by starting the conversation around SDOH factors. The Social Determinants of Health Assessment solution scales across the Outcomes nationwide network of pharmacies—this is done through a narrowed set of validated questions, standardized documentation and detailed reporting. Assessment questions are based on the validated questions from the Accountable Health Communities Health-Related Social Needs tool by the Centers of Medicare and Medicaid Services (CMS). They focus on high need areas like food, housing and transportation, which align with proposed quality measures in the SDOH space. Responses to assessment questions, as well as an inventory of which health-related social needs were addressed by the pharmacist, are all available within reporting to the patient’s health plan.
Pharmacists are uniquely positioned to screen patients for social determinants of health because of their accessibility and footprint in the community. Like many of my fellow pharmacists, I feel a deep sense of purpose and commitment to ensure patients achieve the best outcomes. Though facilitating this conversation can be challenging, the benefit we stand to gain from learning more about our patients makes proactive SDOH consultations the right direction for our profession. The Outcomes network is full of pharmacists who have a strong presence in their community and are likely already facilitating conversations on the topics of job instability, food insecurity and housing access. It’s time to start collecting SDOH information in a more standardized way and compensating pharmacists for their role in these efforts. Through this assessment service, Outcomes can assemble data that enables payers to uncover patient needs for services related to SDOH. The success of medical treatment is dependent on resolving unmet needs related to SDOH, making this information vital to improving adherence and achieving high performance in quality measures for health plans. The National Committee for Quality Assurance (NCQA), a leading organization that establishes quality measurements, is preparing a quality measure that includes screening for SDOH factor metrics and referrals in its performance evaluation criteria for payers.
