Connecting the SDoH Dots Using a Journey Mapping Approach

By Health Ideas Staff
Jan. 14, 2020

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Marketers have long used journey mapping to understand how consumers interact with a brand, using that intel to inspire a desired action — in the case of retail, for example, converting visitors into satisfied customers. Analyzing the behaviors, preferences and pain points of a particular audience allows organizations to intervene if necessary to create a positive, frictionless experience that keeps customers active and engaged.

With increasing emphasis on patient satisfaction as a quality measure, improving the patient experience has made its way to the forefront of the conversation about healthcare reform. But as healthcare simultaneously becomes more complex and consumer-centric, so too has the consumer journey. The rising prevalence of multiple chronic conditions, paired with an urgent effort to increase quality and reduce costs, has led to the recognition that a health outcome is driven by much more than a medical diagnosis and associated treatment; rather, socioeconomic factors such as access to food, shelter and transportation — known as social determinants of health (SDoH) — are estimated to be responsible for up to 80 percent of a person’s health.

Particularly concerning high-risk populations, for whom access to healthcare resources may be lacking, the consumer journey is multidimensional, which makes identifying and addressing SDoH in an effective way a challenge for all stakeholders. Exacerbating that challenge is the fact that a real, empirical standard for SDoH screening has yet to be seen, placing the responsibility largely in the hands of healthcare organizations, including payers, providers and care delivery networks, to set the benchmark — and, as value-based care models dictate, drive measurable value within a set time frame.

Here, we’re exploring journey mapping as a means of improving the healthcare bottom line by enhancing efficiency, satisfaction and outcomes.

Proactively Identifying & Mitigating Health Risk

Because health outcomes are influenced by a combination of medical, behavioral and social determinants, proactively identifying one risk factor is vital to predicting the likelihood of others. If, for example, a low-income individual with high medical needs suddenly loses a family member, caretaker or support system, we know that the individual is at a higher risk of emotional or financial distress — and that appropriate and timely intervention is critical to prevent a negative outcome.

Be There on the Journey

SDoH are ambiguous and ever-changing by nature, which is a big part of what makes identifying and addressing them so difficult. While payers must ask the right questions during member onboarding, and providers must ensure adequate post-care follow-up, the data these efforts yield should only provide a baseline for future engagement. Checking in at multiple points of the journey, monitoring changes in responses over time and measuring self-reported member behaviors against the benchmarks will provide you with the insight to identify risk, intervene promptly and scale up your efforts to meet the needs of the populations you serve.

Maximize engagement opportunities by providing immediate assistance in the form of a warm handoff to care management whenever possible, or offering a callback from a care team member at a more convenient time.

Using Claims to Tell the Story

Claims data can be a powerful tool in understanding a patient’s medical journey. But while a number of ICD-10 codes related to SDoH exist, as the Alliance for Health Equity notes, utilization of these codes has historically been poor. This has prompted an initiative between United Health Group and the American Medical Association to significantly expand the number of SDoH-associated ICD-10 codes and streamline the collection, processing and integration of these determinants into a patient’s care plan. When combined with medical data, the codes could trigger referrals to appropriate community resources based on the individual’s unique and comprehensive healthcare needs.

Using claims data to put health services into the context of the full patient journey can inform inefficiencies impacting the cost and coordination of care. The expansion and improved utilization of ICD-10 codes for SDoH should provide better insight into the wide-ranging factors influencing a patient’s health and enable care teams to address them in a more meaningful way.

Embracing Innovation

Today’s most successful product and service providers have a way of understanding what it is we want and need, often before we’re able to articulate it ourselves. And if we’re going to systematically improve healthcare processes and outcomes, healthcare professionals, policymakers and innovators must work together to carve a similar path.

Creating the infrastructure to effectively map the multitude of factors affecting health and wellbeing at both individual and population scale is no doubt a big undertaking, but with the right level of engagement, analytics and technology, we will begin to see real, sustainable progress.


How are you leveraging SDoH data to improve the patient experience?

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