Posted on: April 27, 2022

After 9/11, a general heightened awareness took hold among the public. “If you see something, say something” became a mantra used to empower citizens to take notice of their surroundings in an effort to keep one another safe.

Now that the pandemic has exposed the disparity in health equity—the ability for all individuals to achieve their full health potential—it’s time for the healthcare community to adopt a “see something, say something” mentality to improve population health.

As a broad healthcare community, we recognize the 80/20 rule applies to health, with 80 percent determined by social, environmental, behavioral and lifestyle factors and only 20 percent by medical services. For that reason, we are increasingly recognizing that community-based organizations (CBO) play an important role in addressing a community’s social determinants of health (SDoH)—and that their efforts must be integrated with care provided in a clinical setting.

Many of these efforts have focused on addressing SDoH to achieve the triple aim—improved patient experience, improved population health and lowered overall cost—as much as a means to improve health equity. As a result, health plans, CBOs, digital health platforms, some providers and other stakeholders in the health system are taking collective action to connect patients with appropriate services based on their social needs. Yet mainstream providers—often the first to see something—haven’t always had an easy way to say something, largely due to stagnant workflows, reimbursement models, and other factors like one-off efforts by well-intentioned organizations that benefit some, but not all, patients in the community.

The opportunity to make SDoH integration a mainstream effort is one impetus behind emerging, collaborative standards such as the Gravity project, OpenReferral and SMART on FHIR. These technologies simplify the exchange of data necessary to integrate clinical and social care. They do this by inserting tools seamlessly into providers’ workflow that offer the ability to exchange information―in a standard way―between clinical and social care providers. Information like documented SDoH and referrals for social services.

But providers are part of the effort, as well. It’s only through a wholistic approach to patient care, one that encourages providers and care managers to monitor patient progress and adherence with social care services, that ensure the social issues preventing a patient from achieving their maximum health potential are fully addressed by the CBO.

Overall, the focus of these combined efforts is twofold. On one hand, it’s about making providers’ process for referring patients to social service organizations efficient and targeted, so that people are matched with the right resources at the right time. On the other hand, it’s about ensuring that scarce social resources are managed and maximized as fully as clinical resources. Together, they help give providers a way to say something, which is needed―especially right now―as the integration of social and medical care is relatively immature

By effectively integrating SDoH referrals into the workflow and closing the loop, we provide emergency, primary care providers, as well as other providers and care coordinators with the power to see something and say something. And that leads to gains in health equity for everyone.

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will be impacted and unavailable—including access to the provider portal.