Social determinants of health (SDOH) challenges can create compounding health issues for patients and put a greater strain on the healthcare system. Multiple parties, including healthcare organizations, payers, community-based organizations (CBOs), vendors, and government entities can partner to address SDOH needs and improve the health of communities.
In 2024, KLAS presented 13 such partnerships with the SDOH Points of Light recognition to celebrate successes in transforming patient and community care. Each partnership’s case study below includes information about the challenges these partnerships faced, the outcomes they achieved, and the key lessons they learned.
In October, KLAS hosted the Social Determinants of Health Summit 2024. There participants voted on the most impactful of these partnerships, which received Wayfinder Recognitions. Case studies representing those partnerships are marked with asterisks below.
Case Study 1: Identifying SDOH Needs & Connecting Patients with Resources
Tracking nonclinical health factors and using that information to connect patients with relevant programs require significant effort. In this partnership, collaborators worked with Unite Us to identify available community resources, provide referrals, and track resource usage.
Case Study 2: Reducing Readmissions with Effective Interventions
Managing treatment plans for high-risk patients and preventing readmissions can be difficult. In this partnership, collaborators created holistic treatment plans, referred patients to community programs, and conducted SDOH screenings and interventions to lower readmission rates.
Case Study 3: Implementing SDOH Surveys without Negatively Impacting Care Delivery
Screening for SDOH needs is crucial but can add to clinicians’ already heavy workload. Collaborators in this partnership created a self-service SDOH survey for patients and combined insights, resources, and planning methods to connect members with community resources.
Case Study 4: Implementing a Screening & Referral Process for Pediatric Patients
Obtaining and tracking SDOH information for pediatric patients often presents a challenge. In this partnership, the healthcare organization partnered with Innovaccer and Findhelp to introduce a closed-loop SDOH screening and referral process that connected patients with reliable CBOs.
Women in low-resource settings with limited access to care commonly die during or after pregnancy. Collaborators in this partnership implemented a comprehensive maternal health program and used Get Well’s and Findhelp’s products to engage and connect patients to resources.
Case Study 6: Deploying a Diabetes Prevention Program
Prediabetes is common in the US, but identifying individuals at risk and improving their health is difficult. Collaborators in this partnership developed EHR automation to identify patients at risk, created bidirectional referral communications, and connected patients with interventions.
Case Study 7: Connecting LGBTQ+ Patients with Educated & Affirming Providers
Many LGBTQ+ patients avoid receiving care because of negative past experiences with providers who weren’t affirming or were inexperienced with LGBTQ+ communities. In this collaboration, Healthgrades partnered with a CBO to increase LGBTQ+ patients’ access to affirming providers.
***Case Study 8: Giving Hope to Youth through Mental Health Support
Following COVID-19, feelings of hopelessness increased significantly among high school students in the US, and caring for children with behavioral health conditions is costly. Collaborators in this partnership created a preventative program to identify and assist at-risk youth with SDOH needs.
Case Study 9: Creating a Community Connection Platform for Idaho Residents
During COVID-19, many Idaho residents needed access to resources for the first time but didn’t know where to find them. Collaborators in this case study created a user-friendly database of resources that can be used individually and organizationally to address community needs.
***Case Study 10: Addressing Social Health Disparities among Medicaid Members
Elevance Health and Findhelp partnered to offer an incentive program to standardize SDOH-need identification among Medicaid members and encourage resource referrals. PM Pediatric Care used this program and Findhelp’s product to connect children with community resources.
Case Study 11: Using AI & Community Partners to Enhance Patient Care
Saint Peter’s University lacked an SDOH screening process, so they implemented screenings and partnered with Lightbeam Health Solutions to synthesize the data and create care plans. The data was shared with Healthier Middlesex, who connected patients to community resources.
Case Study 12: Reducing Costs by Practicing Whole-Person Care
Patients with complex needs can be expensive to treat and may overuse resources. This partnership used Lightbeam Health Solutions to identify SDOH issues and enhance engagement while developing an aligned care approach with clinics and community resources to save on costs.
Case Study 13: Forming a Governance Committee to Address Patients’ HRSNs
Collaborators in this study reduced ED visits and enhanced access to resources. They formed a committee to allocate resources, created a platform to identify SDOH factors, integrated SDOH data into clinical software, and created community health worker positions with CMS funding.
***The partnerships in these case studies were presented with a Wayfinder Recognition according to participants’ votes at the Social Determinants of Health 2024 summit.
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