Using Data to Address Social Determinants of Health

We’ve all seen the research that shows that health care and genetic code contribute less to overall health and well-being than individual behaviors and zip code. In fact, data shows that clinical care contributes about 20% towards overall positive health, while non-clinical or social needs like housing stability, education, employment, family and social supports, and personal safety are twice as impactful.1

As I wrote in my previous post, I believe a multi-pronged strategy is needed to meet the complex needs of our members and partners. The health care system and the human services and housing systems need to be better integrated and there needs to be a more holistic approach to care—an approach that requires not only changes in policy, but changes in practice as well.

Almost any effort to better align and collaborate across systems will first require the ability to better analyze data across systems. Some Medicaid health plans, like UnitedHealthcare, are using data from diagnoses, utilization, and quality gaps to identify high-risk members and determine best approaches to care. We are also using non-health care data like housing status, child welfare and criminal justice involvement to help us better understand and identify community-level need, develop linkages to resources, and track health and other life outcomes. Seeing “the big picture” helps us more effectively support those served by Medicaid, and impact and improve outcomes.

At UnitedHealthcare, we have several initiatives underway using data and analytics to better understand health care needs, identify health care trends, and work to improve care.

Our health care Hotspotting tool allows us to identify member cohorts by risk factor, geography, diagnosis, utilization, cost of care, social situations, and other factors. The strategic use of data then allows us to identify pockets of high-need, high-cost consumers and deploy resources to the right members at the right time. This is particularly important when we are targeting populations for a specific intervention.

As part of our Aligning Housing and Housing Systems project, in conjunction with the Corporation for Supportive Housing and the Council of Large Public Housing Agencies (PHA), we are using data to identify UnitedHealthcare Community Plan members living in publicly-assisted housing administered by PHA. We are analyzing the data from this shared population to identify population health trends and health care issues faced by these residents. We are currently partnering with six public housing agencies in three states to develop data-driven population health intervention strategies to better serve PHA residents, with more partnerships coming.

As we look to the future, we are exploring ways we can partner with other systems as well. Opportunity areas include working with county jails and state prison systems to improve transitions back to the community and working with county human services agencies to better support children and families in the child welfare system. The challenges of accessing and analyzing data and aligning resources and efforts across systems can be daunting. However, we believe it is a key pathway for improving health outcomes, and are committed and up to the task.

[1] https://uwphi.pophealth.wisc.edu/chrr/

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