socially determined corporate overview
TRANSCRIPT
SOCIALLY DETERM IN ED
Socially Determined Corporate Overview Social Determinants of Health –
From Analytics to Action
September 2018
SOCIALLYDETERMINED
Socially Determined’s Significant Seven
ECONOMIC WELLBEING
How income, employment, access to benefits
and financial security affect health and health
care
HOUSING
How the characteristics of dwellings within an
area affects the health and healthcare of the
people living there
TRANSPORTATION
How the availability, accessibility and safety of
transportation in a neighborhood affects health
and health care
FOOD INSECURITY
How being without reliable access to a
sufficient quantity of affordable, nutritious
food affects health and health care
+
CRIME & VIOLENCE
How the prevalence of crime, violence and
legal challenges in a neighborhood affects
health and healthcare
HEALTH LITERACY
How the ability to obtain, read, understand,
and use healthcare information to make
decisions and comply with treatment affects
health and health care
SOCIAL SUPPORT
How the availability of assistance from other
people and the feeling that one is part of a
supportive social network affect health and
health care
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SOCIALLYDETERMINED
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Patient Journey
2 Screening & Assessment
• Utilizing data analysis to screen
patient
• Conduct secondary assessments
based on positive screens
• Identify specific subpopulations
Social Care Plan
• Identify key subpopulations
• Create social care plans and
referral strategies in clinical
context
• Catalog internal capabilities
• Create directory of community
services
3
4 Referral & Connection
• Educate patient on process and
personal role and support available
• Institute’s internal care
management
• Referral to external resources
• Share data and social care plan
5 Fulfillment & Tracking
• Track referral completion
• Measure outcome and
utilization measures
• Refine analytics based
upon ROI
• Iterate model based on
value based results
1 Data Collection & Analysis
• Collect and analyze SDOH data
• Collect clinical data and claims data
• Leverage commercial data
• Create a proactive process to target
specific patients based upon
analysis
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SOCIALLYDET ERMINED
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Advanced data analytics to quantify/visualize risk factors
SD Analytics
Machine Learning
Pipeline
Principal Components Analysis
Clustering Algorithms
Inferential Networks
COMMUNITY
RISK
INDICES
SD Curated
Community Data
Clinical/claims data
from customer
COMMUNITY
VULNERABILITY
METRICS
SDOH INDICES
SDOH
POPULATIONS
SDOH
INTERVENTION
MODELS
SDOH
RISK
INDICES
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ea lth Care Providers
Business
Social Services
Populations
0 All Med icaid
0 High ED Utilizer
0 NICU Moms
Median Income
Visible Area
$15,161
Cuyahoga County
$43,000
Ohio
~ 2,000
SOCIALLY D ET ERM INED
Avon Lake
Avon
North Rulgev1lle
Central Buckeye-Woodh Ill
Brooklyn Centre Hough
Kinsman Fairfax
St.Dair-Superior
Dark-Fulton Untversity
Mount Pleasant -
Wes tlake
ColumbooTwp
Highest Risk Neighborhoods
farrna
North Macedooa Royolon
Economic Scorecard
3 Risk Index
3 Viability Index
3 Growth Index
Twinsburg
500,000
'400,000
300,000
200,000
100,000
Search for Places
Chester Twp
Bonbndge Twp
Au rora
Risk Distribution
4
II
Auburn T
4.5
SocialScape™ Navigator Browsing consolidated social determinant data in communities
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High concentrations of poor outcomes in 3 clusters
6 neighborhoods comprise half of total NICU babies
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15% -_
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SOCIALLYDETERMINED
Central
Clark-Fulton Stockyards
Brooklyn
Centre
Old
Brooklyn
Broadway-Slavic
Village
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SOCIALLYDETERMINED
Neighborhood Risk Profiles & Prioritization
# Babies % NICU
Births
Avg. Cost
of Initial
Stay
Median
Income Economic
Index Food Index
Transportation
Index Housing
Index
All Medicaid
Pregnancies 5,027 14.6% $45,530 $41K 3.2 3.6 3.1 4.3
Neighborhood 1 348 15.2% $39,816 $30K 3.4 4.1 3.4 4.8
Neighborhood 2 162 17.3% $22,899 $30K 4.7 4.1 4.0 4.9
Neighborhood 3 324 16.0% $39,144 $41K 4.4 3.4 4.1 3.3
Neighborhood 4 263 14.4% $40,666 $34K 4.8 3.9 4.4 4.4
Neighborhood 5 231 12.1% $32,642 $30K 4.9 4.7 4.2 4.9
Neighborhood 6 393 16.0% $61,696 $19K 3.1 4.3 3.2 5.0
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High Risk Patient Archetype: Social & Clinical
Clinical Reality Social Challenges
Makes less than 1 in 4 have mental illness or $27,500 per year
85% do not have bank
accounts or credit
Low Educational
Attainment
40% Evicted at
least once
9 out of 10 are
unwed
substance abuse issues
Likely has one or more
conditions (diabetes,
hypertension)
complicating pregnancy
Typically will not
attend all pre-natal
appointments
Age 26-35, multiple
children
Social Independence
as the antidote
Has income greater
than $33,000
Level or positive
address trajectory
Attended
college
Has name on
housing lease
SOCIALLYDETERMINED CONFIDENTIAL AND PROPRIETARY—DO NOT DISTRIBUTE 9
-
RED CARPET
mom
SOCIALLYDET ERMINED
5 Neighborhoods 500 Moms 18 21 Months
Red Carpet for Mom Neighborhood Oriented Social & Clinical Intervention Campaign
SDOH
“Essentials”
Key Design
Food Prescription Transportation Stable Housing Integrated Behavioral
Program Health and Addiction
Services
Elements
Social Support Networking Technology Enabled
Center(s) – In-Person and Care Ecosystem
Virtual
Personalized
Wellness and Social
Care Plan
Self-Sufficiency
Programs to Drive
Sustainability
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@
SOCIALLYDETERMINED
2018-2019 Road Map 2018 2019
8 9 10 11 12 1 2 3 4 5 6 7 Beyond
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Maternal
ER
Avoidance
MSSP
Pain
Activation Enrollment and Baseline Performance Year 1
Activation Enrollment and Baseline PY1
Activation Enrollment and Baseline PY1
Activation Enrollment and Baseline
C
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t
s
Analytics
Analytics
Analytics
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Next 45 Day Work StreamsBegin the RFI process and explore partnerships with frontrunners
RFI/MOU Candidates
Food Transportation Mental/Behavioral Digital Care Platform
Grocery Vouchers
Prepared Meal Delivery
Meal Kit Delivery
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Campaign Activation Themes Analytics Program Management
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The Social Care PlanAnalytics and the enrollment screening inform a personalized care plan for mom
Enrollment Screening Social Care Plan
Food Programs
Food Farmacy
SNAP Enrollment
Meal Delivery
Transportation
MetroHealth Van Program
Coordinated Lyft Rides
Transit Vouchers
Patient Advocate
Weight Management Plan
Centering Program
Housing Support
Pest/Mold Remediation
Respite Location Access
Lead Paint Abatement
Behavioral Health Services
Telemedicine Counseling
Provider-led Peer Group Program
Integrated Psychiatric Care
Home Visits (NF Partnership)
Diagnostic Testing/Vaccination
MFM Specialist Access
Clinical Care Component
5 Neighborhoods 500 Moms 21 Months
Target Neighborhood SocialScape Partner Procurement
Risk Profile & Intervention Match Social Funding & Matching
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Social Investment & Partnership
RFI/MOU Candidates
Corporate Partners Foundations City/State Payers
Red Carpetv
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SOCIALLYDETERMINED
MetroHealth
~ PROMEDlCA I WELL CONNECTED.
UPMC LIFE CHANGING MEDICINE
((,"Catholic 'JJHealth
Care Source·
fiiln PARAMOUNT
UPMC HEALTH PLAN
lndeP.endent 9 Health.
2018-2019 Active Partnerships Targeting regional partners with strong Payer/Provider Integration
Region Provider Plan Population Patient Focus # of Patients
Northeast Ohio 2018: Medicaid
2019: Medicare
Maternal Health
ED Utilization
Chronic Disease ~165K
Diabetes
Northwest Ohio All Patients ED Utilization ~640K Food Security
Pediatrics
Western PA All Patients Breast Cancer ~700k Transportation
Cardiology
Western NY All Patients Metabolic/Obesity
Bariatric ~400k Maternal Health
5 Regions All Seniors Social Isolation ~1.5M
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