A tool for addressing social determinants of health to improve care for vulnerable populations

Social and economic factors have been shown to have the largest impact on an individual’s health as well as the long-term health of communities. As a Medicaid Accountable Care Organization (ACO), Partners HealthCare System (PHS) developed and implemented a questionnaire at primary care sites across the system to learn how these social determinants of health (SDoH) influence our patients’ health and inform strategies to mitigate those risk factors.

We created a live Tableau dashboard using data queried from the PHS Enterprise Data Warehouse to visualize the myriad demographic and SDoH data being captured in our electronic health record system, including which patients have been assigned a questionnaire, questionnaire responses, referrals made in response to patients’ answer(s), and the resolution to any referrals, if there was one.

The dashboard is being used by leaders at our practices to observe operational and performance metrics related to the SDoH questionnaire administration workflow and patient care. Using the dashboard, they have been able to identify patients who are screening positive for unmet needs but have not received a referral as a result, and patients who received a referral but did not have follow up on those referrals to close the loop. They have also used the data to guide staffing of community resource specialists and community health workers in response to the number of patients screening positive. Looking forward, we plan to use the tool to guide how government funded support for the Medicaid ACO program can be best spent to meet patients’ needs.

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