1. Integrating Social Determinants of Health Into Clinical Care Data, Research and Care Delivery
Andrew Bazemore, MD, MPH
Director, Robert Graham Center
Visit with University of Utah
March 2016

3. In an average month: New Ecology of Medical Care – 2000, NEJM
1000 people
800 have symptoms
327 consider seeking medical care
217 physician’s office
113 primary care
65 CAM provider
21 hospital clinic
14 home health
13 emergency
8 hospital
<1 academic health center hospital
New Ecology of Medical Care – 2000, NEJM

4. Our future must be team-based, and integrated with Public, Community and Behavioral Health

5. Large Implications for the effective Care of Complex Chronic Disease, which already principally occurs in PC

6. RGC has a longstanding interest in contextualizing health using GIS
RGC has a longstanding interest in contextualizing health using GIS And in linking clinical and population health data
Street Addresses
Streets/Rivers/Land Features
Hospital/Medical Center/ Clinics
Zip Codes/Counties
Spatial Analysis – (i.e.travel times)
Service Demand/Provider Density

7. …in effective data visualization…

8. Or combining multisource geospatial data to create an index of Social Deprivation and allow the better targeting of resources

9. Or in informing effective resource allocation to support the U. S
Or in informing effective resource allocation to support the U.S. Primary Care‘Safety Net’

10. What % of Low-Income population remains unserved?

11. … or visualizing social accountability in Medical Education

13. Quantum Shift to Population Based Health Care
Or in helping Australia Understand its Primary Health Care Reform & the
Quantum Shift to Population Based Health Care

14. Practice level Medicaid Data + Costs + Dz Prevalence + SDH

16. Can geographically-directed prevention change outcomes?

17. …in support of local primary care development & advocacy Why should we support you? So many of your patients come from outside of DC” (DC City Council)
Unity Service Area (2007)
N= 77,400
(Service Area Threshold 70%)

18. “Why have 2 sites in the same neighborhood
“Why have 2 sites in the same neighborhood?” (Washington DC City Council)
Hunt Place HC
Service Area (2006)
East of the River HC
Service Area (2006)

21. …in their use for improvement of community health21

22. and in the provision of Primary Health Care in a Community Context (Community Oriented Primary Care)
Drs. Sidney and Emily Kark early 1940s
Developed COPC into a model of community engagement for improving health South Africa, Australia, Israel….the US

24. Other Pioneers
Farley and Froom
Curtis Hames
Weed and Schultz

25. Contemporary Context

26. IOM Report: Social Determinants

27. Using Secondary Data instead of Patient Report?

28. Making sense of a tsunami of data

29. Opportunities in an age of Big Data & Geographic Information Systems
Street Addresses
Streets/Rivers/Land Features
Hospital/Medical Center/ Clinics
Zip Codes/Counties
Spatial Analysis – (i.e.travel times)
Service Demand/Provider Density

30. Our Approach

33. Our Approach

34. Community-level SDH domain
Example Indicators
Data Source
Built Environment
Population density
American Community Survey
U.S. Census Bureau, County Business Patterns
U.S. Census Bureau, ZIP Code Business Patterns
Environmental Exposures
Percent of population potentially exposed to water exceeding a violation limit during the past year
Environmental Public Health Tracking Network, Environmental Protection Agency
Safe Drinking Water Information System, Environmental Protection Agency
Neighborhood Economic Conditions
Overall percentile ranking for the Centers for Disease Control Social Vulnerability Index
Agency for Toxic Substances and Disease Registry (ATSDR)
-Neighborhood Stabilization Program, US Department of Housing & Urban Development
Neighborhood Race/Ethnic Composition
Count and percent by race

35. Community-level SDH domain
Example Indicators
Data Source
Neighborhood Resources
Urban Classification Code
-Environmental Public Health Tracking Network, Environmental Protection Agency
-Centers for Disease Control and Prevention
-U.S. Census Bureau, County Business Patterns
-U.S. Census Bureau, ZIP Code Business Patterns
-U.S. Census Bureau; USDA Food Access Research Atlas
-USDA Food Access Research Atlas
-USDA Food Atlas
-USDA, ERS
Neighborhood Socioeconomic Composition
Median household income
American Community Survey
Social Deprivation Index
A composite measure of social deprivation

36. Social Depreivation

37. Population Health Assessment
SDH Library
Geocoding API
ACHIEVER Proposal
(RGC/OCHIN)
PRAPARE TOOL
Analytic Tools
Patient Reported SDH
Community SDH
Clinical Outcomes
CLINCH-IT
Outreach
Population Health Assessment
Point of Care
Clinical Payment Policies/Risk Adjustment
Referrals/Clinical Action

38. What is next?
Working with OCHIN EHR vendors to embed this into one or more EHR interfaces
Using PCORnet to study SDH as a modifier
Grantwriting/studies to better understand use of integrated data

39. Summary
Social determinants of health significantly impact morbidity and mortality; however, physicians lack ready access to this information
“Community vital signs” can provide an aggregated overview of the social and environmental factors impacting patient health
To inform clinical recommendations for individual patients,
To facilitate referrals to community services,
To expand understanding of factors impacting treatment adherence and health outcomes.
To help care teams target disease prevention initiatives and other health improvement efforts for clinic panels and populations.

40. Summary
Advances in big data, geospatial technologies, and democratization of data make integrating Community VS into practice data, enterprise research data, and practice-level decisionmaking
The science guiding the use of SDH in practice and patient-level decisionmaking is scarce.
We must build the tools and the science simultaneously

41. Who We Are: A Family of Primary Care Scholars
Questions?
115 Larry A. Green Visiting Scholars
12 Robert L. Phillips Policy Fellows
Dr. Laura Makaroff, now a Medical Officer for HRSA Bureau of Primary Care