Improving and promoting social determinants of health at a system level

BACKGROUND: Social determinants of health (SDoH), such as low socioeconomic status, race and ethnicity, poor environmental conditions, food insecurity, and inadequate access to health care services, are known to adversely affect health outcomes. The aim of this project is to address SDoH needs with clinical care to further improve patient outcomes and assist safe discharge. APPROACH: Prime Healthcare Service's model to address SDoH needs focused on supplementing its existing care coordination process with digital innovation while leveraging its highly skilled multidisciplinary team of physicians and mid-level providers, care coordinators, case managers, and social workers and strengthening its relationships with community partners. Prime extended the scope of its services by growing its providers and care navigators' presence in the community to assess needs and foster hospital-community relationships to meet the needs of individual patients. RESULTS: The 2021 Lown Hospital Index, which includes matrices Equity, Value, and Outcomes, has ranked Prime Healthcare Services, as a system, #1 overall in New Jersey and Nevada states. It also ranked Saint Michael's Medical Center number 2 in New Jersey for social responsibility, Centinela Hospital Medical Center number 9 in California for clinical outcomes, and St. Joseph Medical Center number 3 in Missouri for outcomes. The Index also ranked North Vista Hospital as the number 1 most racially inclusive hospital in Nevada. The acute myocardial infarction (AMI) 30-day risk-standardized mortality rate was reduced by an average 1% across the system, while the risk-standardized AMI complication rate was at 0%. CONCLUSION: Development of an SDoH screening tool, prioritizing high-risk factors, involving a multidisciplinary team, and strengthening the post-acute network have helped address and link the role of SDoH factors in patient outcomes and has resulted in reduced readmission rate, lower mortality and complications rate, and improved cost alignment with the Centers for Medicare & Medicaid Services payment reforms initiative and value-based care.