Industry leverages partnerships, social needs data to address COVID-19

When COVID-19 hit, Carilion Clinic used its arsenal of social determinants of health data to figure out which patients would need the most education and support throughout the pandemic.

With help from an artificial intelligence vendor, the Roanoke, Va.-based health system used ZIP code and census data and other social needs data to identify thousands of patients most at risk for negative outcomes should they contract COVID-19. Data from electronic health records was also used.

Carilion Clinic staffers called those patients routinely, asking how the system could help with such social and health needs as food insecurity and medication refill challenges. The patients were also educated about the importance of social distancing, hand hygiene and mask wearing.

“They knew they had this lifeline during this pandemic should they need it,” said Donna Littlepage, senior vice president of accountable care strategies at Carilion Clinic.

Carilion Clinic’s experience reflects that of many providers, health plans and public health officials who presented at Modern Healthcare’s 2020 Social Determinants of Health Symposium last week. Homing in on social determinants has been a large part of the strategy to address challenges brought on by COVID-19, many of the executives said. Their focus is supported by data showing minority populations and low-income individuals are far more likely to contract and die from the virus.

Throughout the virtual conference, industry leaders consistently said they rely on data sources that offer a glimpse into the social challenges their population faces along with trusted community partners to help them identify where to invest resources during the crisis.

For instance, during the first surge of COVID-19 Ohio State University Wexner Medical Center relied on longtime partnerships with community organizations to help deploy mobile units in disadvantaged communities. The mobile sites offered COVID-19 testing, masks and hand sanitizer.

“In each of these efforts it’s about working with the local community on establishing trust,” said Dr. Harold Paz, CEO of Wexner Medical Center.

Wexner’s relationship with community partners will help when COVID-19 vaccine distribution begins, Paz added. The industry is focused on ensuring minority and low-income populations have access to the vaccine, but Paz said some may be hesitant to take it if there isn’t a solid, trusted relationship between the health system and the community.

Community health organizations are eager to partner with health systems on addressing social determinants of health. “There is no competition here, we are all about the same thing, and we want to work with you, but you have to invite us in,” said Suzanne McCormick, U.S. president of the not-for-profit charitable coalition United Way Worldwide.

Acquiring social determinants of health data is another area where healthcare organizations should be on the lookout for partners, said Marc Gourevitch, chair of the public health department at NYU Langone Health.

“There really is a tremendous wealth of data that others have assembled … one can cover a lot of ground by picking up the phone and assessing what is already out there,” he said.

For instance, a risk predictor tool for Type 2 diabetes and lead exposure developed by AllianceChicago, a consortium of federally qualified health centers, used data from the YMCA and other social service organizations, rather than just healthcare.

“It broadens the scope of the diversity of data that could be used to power the analytics,” said Andrew Hamilton, chief informatics officer of AllianceChicago.

Social risk factor data is being used by California officials to decide what COVID-19 restrictions should be in place at the county and state levels.

California has created an index that factors in 25 measures related to social needs such as education, transportation, environment and socio-economic status. A county can’t reopen certain business activities until the test positivity rate for those in areas with high social needs is similar to the rest of the county.

“COVID doesn’t respect census boundaries,” said Dr. Alice Hm Chen, deputy secretary of policy and planning at the California Health and Human Services Agency.

Despite how helpful social needs data has been as the industry responds to the COVID-19 crisis, it’s still flawed.

Data is usually outdated—often two to three years old—and not specific enough to allow providers and health plans to drill down to individual populations in counties, said Eric Hunter, CEO of managed-care plan CareOregon.

Additionally, it’s far too difficult to share data from public entities and private ones, said Janet Hamilton, deputy director of Portland, Ore.-based not-for-profit Project Access NOW.

“We have so many data silos that are preventing people from doing effective care coordination,” she said.