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The prescriptive analytics company will start by helping researchers the Novant Health Institute of Innovation & Artificial Intelligence reduce readmissions for congestive heart failure.

Contra Costa Health Services takes on whole person care by gathering every bit of data, not just medical care data, and getting it into its Epic EHR. The results have been startling.

As part of its Healthy Opportunities Initiative, the North Carolina Department of Health and Human Services has enlisted Phreesia to help health systems statewide learn more about their patients' social determinants of health. WHY IT MATTERS Phreesia, patient intake platform is able to screen patients for unmet social and environmental needs that could be adversely affecting their health. It poses questions patients about various social factors and can deliver real-time alerts for providers and care coordinators, helping them better target care interventions. In addition, its analytics and reporting help health systems with population health management. Phreesia's technology will deliver North Carolina's Standardized Social Determinants of Health Screening Questions to providers across the state – helping them spot patients who may be helped by addressing certain social factors, enabling providers to be more attuned to their holistic health. Additionally, NCCARE360, North Carolina's first coordinated network connecting healthcare and human service providers, is being deployed statewide, making it easier to connect people with resources according to their needs. THE LARGER TREND Phreesia, which went public earlier this summer, points to research from Kaiser Permanente that suggests most patients want their providers to ask about their social needs and help connect them to resources. As Healthcare IT News focuses this month on social determinants of health, we've been exploring the wide variety of factors – from housing to food insecurity to domestic safety – that can have huge effects on a person's health. In North Carolina, according to the state DHHS, more than 1.2 million people cannot find affordable housing, and one in 28 children under age six is homeless. More than one in five children are living in food-insecure households, and nearly half (47 percent) of North Carolina women say they have experienced intimate partner violence. Helping connect these people with community-based programs could help, and many new initiatives are being launched to do just that. But first, providers need to know that their patients are in need. ON THE RECORD "To advance the health and well-being of North Carolinians, we need to build a coordinated, whole person-centered system that addresses both medical and non-medical drivers of health," said DHHS Secretary Dr. Mandy K. Cohen in a statement. "Our partnership with Phreesia will make it easier for doctors and other health care providers to ask patients about their non-medical health needs, which are a critical component of their overall health." "We're excited to collaborate and support NC DHHS on this important initiative," said Phreesia CEO Chaim Indig. "Helping providers identify patients' social needs allows us to further our mission of improving the healthcare experience, and we look forward to continuing this work in communities across the country." .jumbotron{ background-image: url("https://www.healthcareitnews.com/sites/hitn/files/u2556/SocialDeterminantJumbotron.jpg"); background-size: cover; color: white; } .jumbotron h2{ color: white; } Focus on Social Determinants of Health In September, Healthcare Finance News, Healthcare IT News and MobiHealthNews will take a look at the SDOH and how varied health systems, IT companies, Congress and others are addressing it. Twitter: @MikeMiliardHITN Email the writer: mike.miliard@himssmedia.com Healthcare IT News is a publication of HIMSS Media.

Plans will jointly operate 14 community resource centers across Los Angeles that will leverage personalized technology solutions to improve health.

At Health 2.0 this month, seven disparate companies will show how their apps and platforms are being put to work leveraging clinical and social data to drive innovations in care delivery.

Three representative vendors discuss why social determinants of health are important to population health management, and describe how their technologies help put these important data points to work.

AI and SDOH developed separately, but they're now converging as technology keeps up with the need to make actionable use of data.

First-of-its-kind partnership uses IT to connect patients to social service organizations in upstate New York.

For much of the history of modern medicine, the model has been that patients go to the hospital or physician to receive treatment. This works well when all of the tools needed to solve a health problem are concentrated in one location. There are some things that an MRI machine or a ward of specialists can't fix though. Food insecurity, lack of reliable transportation, even levels of literacy and education are all factors that can lead to the types of hospital visits that quickly become expensive. Addressing these upstream factors, known as social determinants of health, requires healthcare systems to look outside of their traditional realms and roles. Cindy Gaines, RN, chief nursing officer at Philips Population Health Management, says that a hospital can't solve every problem in the world but it can broaden what it looks at and whom it works with. Data to target, not overwhelm Hospitals need to know what the needs of their population are before they can start finding ways to address them. Gaines says that a community health assessment is an important place to start, followed by other publicly available health data. While trying to address social factors without targeting the needs of specific populations won't get very far, neither will overloading with data. Start with what you have is her advice. "SDoH surveys can be really long and overwhelmed with data," she says. "Even using ZIP code data, you can learn a lot about a community." Seek out partnerships "We take action one patient at a time when we're in the office," says Gaines, who says practitioners might interact with patients who need to make a choice between paying their electricity or their medical bill – and never know. Instead, hospitals need to partner with organizations that fall outside of the healthcare realm. Gaines says she's seen hospitals partner with or even create farmer's markets or food pantries in food deserts. She notes one health provider sponsored a public bike program in one town to address things like obesity and low exercise rates. Making an impact on SDOH means "really being creative about what we want to do" and then finding the right places in the community to partner with or support, says Gaines. Better understanding a patient population and identifying upstream solutions place the hospital in the role of the coordinator. Focusing on the goal of keeping communities healthy means that communicating better with other providers and outside organizations will help target and address underserved populations. Knowing where to look for data as well helps healthcare providers start to develop standards for how to connect those in need with the services that can help them. When better information about patients and situations that impact their health become clear, hospitals can effectively build partnerships and help address environmental factors. Something as simple as identifying patients with transportation needs and providing rides for them to reach an appointment can lead to a huge decrease in spending. "It takes a community to address the social determinants," says Gaines. "It isn't a hospital going out and changing the world on its own." .jumbotron{ background-image: url("https://www.healthcareitnews.com/sites/hitn/files/u2556/SocialDeterminantJumbotron.jpg"); background-size: cover; color: white; } .jumbotron h2{ color: white; } Focus on Social Determinants of Health In September, Healthcare Finance News, Healthcare IT News and MobiHealthNews will take a look at the SDOH and how varied health systems, IT companies, Congress and others are addressing it. Benjamin Harris is a Maine-based freelance writer and former new media producer for HIMSS Media. Twitter: @BenzoHarris.

Momentum for more forward-looking SDOH initiatives is building across healthcare, as stakeholders recognize the key role of socioeconomic factors, environment and community in better health and wellness. But unlocking ROI will take some work.