Imagine a man named Reggie.
Reggie* is a man grieving his wife. She passed away last year after 52 years of marriage. He worked as a physics teacher, his wife was a nurse, and they raised two sons in East Camden, New Jersey. Recently, he has been diagnosed with diabetes and is having trouble remembering his sons’ names.
He is 75 years old, and he walks to the food pantry most days to be able to get a full meal. Walking is hard on his knees, but it’s easier than driving because his arthritis makes it difficult to operate a car.
Even though Reggie lives alone, he does get some help. His neighbor’s granddaughter, Rose, helped set up his social security and enrolls him in Medicare and Medicaid almost every year. She drives him to his doctors appointments where he gets his diabetes and emphysema medications, although her second job often has to take priority. A few local nonprofits have helped him pay his heating bills and given him extra clothing. His physician, Dr. Shah*, also tries to keep an extra eye out for Reggie’s other needs.
The problem isn’t a lack of people who care about Reggie. His doctor, his neighbor, and local organizations all support him in various ways. But here are a few of the ways this support system breaks down—all related to connection failures:
- Dr. Shah doesn’t know how to share Reggie’s clinical information with the soup kitchen that serves him. If he could share it, the soup kitchen would know that the apple pie they regularly serve to Reggie increases his risk for diabetes complications.
- The soup kitchen is in a position to get reimbursed for providing Reggie with food, but they don’t know that MCOs are able to provide that reimbursement, or how to pursue that stream of funding.
- Medicaid would cover Reggie’s transportation to the soup kitchen and to his doctor’s appointments, but neither Reggie nor his neighbor Rose know this.
- Social isolation and dementia are two of the biggest contributors to Reggie’s poor health, and there are social services organizations who would be ready to help if they knew about him.
Reggie’s story highlights the current state of clinical and social care across the country. There are close to 100 million people like Reggie, whose challenges go beyond one single condition or single straightforward need. Instead, they have a web of interrelated medical, social, and behavioral challenges. Nobody has a complete picture of Reggie’s health—and the problem isn’t that nobody cares. The central problem is related to coordination.
SDoH data is uniquely challenging—for a few key reasons.
Payers, providers, government agencies, and Community-Based Organizations (CBOs) are actually fairly well aligned on the fact that Social Determinants of Health (SDoH) matter and that collecting SDOH data has to be a priority across the board.
But here are some of the historical challenges with leveraging that data:
- SDOH, by its very nature, falls across multiple industry segments, from housing and transportation to food access and financial insecurity.
- Very different types of organizations—from soup kitchens and faith-based organizations to payers and primary care providers—need to be able to share data with each other. And without a history of collaboration, there isn’t always a lot of trust between these organizations.
- Technology asymmetry contributes to the divide: CBOs don’t always have the technology to interact with payers, providers, and other stakeholders, which is a difficult starting place for collecting data.
- That data doesn’t just need to be collected—it needs to be standardized and disseminated at local, state, and federal levels.
In other words, interoperability is the overarching challenge when it comes to pulling together all of the information needed to help Reggie effectively and consistently.
What are the bright spots when it comes to delivering better care?
There are bright spots when it comes to the future of SDoH data. The Office of the National Coordinator for Health Information Technology (ONC) is working closely with federal agencies and organizations like USAging to advance the exchange of SDoH data. This summer, USAging and GroundGame.Health, inc. announced a partnership and the launch of a new Interoperability and Data Affinity Group to tackle these precise challenges. Area Agencies on Aging (AAAs) and other CBOss are meeting social and care needs every day. Enabling them to do their work more easily–from an operational and a financial perspective—will accelerate better health and quality of life for millions of Americans nationwide.
Regulatory efforts are already focusing more attention and resources on health equity and cross-industry collaboration. We are on our way to a stronger healthcare system that closes gaps in care and takes a comprehensive view of health and wellbeing. But we know from experience that Interoperability will need to underpin all of it.
6 Elements for Interoperability
Interoperability encompasses several factors that can make a real difference:
- Public policy from CMS and ONC that advances data standards and interchange protocols
- Infrastructure for SDOH data collection, standardization, and dissemination at the state and federal level
- Basic technology standardization at the edge—so that all types of organizations can work together easily
- Integration of resource directories and a view of live resource capacity so that it’s clear which CBOs are positioned to help meet the needs of people like Reggie
- Financial workflows to capture reimbursable activity and power the flow of resources from MCOs to the CBOs that are supporting their members
- A way to keep track of unmet needs and to measure the impact of both the CBO interventions and the resources that MCOs are investing
There are 55.7 million Americans age 65 or older, but the strategies that ONC and USAging are leaning into are relevant across every age group. GroundGame.Health serves as a trusted partner for payers and CBOs alike, with an interoperable platform that allows data and financial resources to flow where they can do the most good.