Leadership Roundtable Series:

Social Determinants of Health Community Insights

For our latest PatientPing Leadership Roundtable, we gathered leaders from across our national network for a virtual discussion on social determinants of health (SDoH) featuring our guest  speaker, Katherine Suberlak, VP of Clinical Programs at Oak Street Health. The focus of the conversation was oriented around assessment, staffing models, and strategies for addressing initiatives around social determinants. See below for key learnings from the roundtable:


Katherine Suberlak kicked off the discussion by sharing approaches that Oak Street Health, a network of primary care centers for adults on Medicare, has taken to address social determinants of health. One of the approaches shared was to utilize a combination of predictive analytics and information that the patient shares at the start of their visit at the clinic via a health risk screening. The screening works to identify patients who may be faced with social determinants by flagging barriers to accessing food, medications, social isolation or substance abuse. If patients indicate such barriers, Oak Street Health’s medical social work team is notified and connects patients with the resources they need. This particular approach works to both identify potential risk at an individual level and analyze the risk from the population level by aggregating data.

Gayle Kataja, Director of Quality and Private Initiatives at Connecticut Community Care, a statewide community-based care management organization, then shared how her organization utilizes the interRAI Home Care “Universal” Assessment and their electronic care management system, called CONNEXUS Care, to screen for social determinants.  With this approach, patient’s care management can be tiered based on social determinant risk scores as coded in CONNEXUS Care using the following codes:

  1. Thriving
  2. Safe
  3. Stable
  4. Vulnerable
  5. In Crisis

PatientPing Pro Tip: Leverage the PatientPing High Utilizer* or Readmission Risk* flags to identify at-risk patients and/or identify community organizations who share a patient relationship by reviewing program attribution.  Additionally, when reviewing patient profiles in PatientPing, access their care summaries, which provide comprehensive overviews of care events over the last 30 days and 12 months. 

*High Utilizer flag identifies a patient that has had 3 or more ED encounters in the last 60 days 

*Readmission Risk flag identifies a patient that was discharged from an inpatient setting within the last 30 days and is at risk for readmission

Staffing Models

At Oak Street Health, one of the critical components of their staffing model is monitoring the highs and lows of their active caseload and identifying high-risk patients. Partnerships are another key component to addressing this topic. Suberlak emphasized, “We can’t do this alone, so building a network of trusted partners helps ensure we’re providing comprehensive resources for our patients in need.” 

On a tactical level, the team that works on social determinants includes:

  • Clinical social workers
  • Community health workers which are thought of as clinical extenders
  • RNs
  • Providers
  • Medical Assistants

Oak Street’s clinical social worker sets the agenda and the team meets every week to review the high-risk patients on that panel. Oak Street Health has found that having one owner and navigator of the work is effective, while the work might be completed by the team.

Christine Cernak, Senior Director of Longitudinal Care at UMass Memorial Health Care, the largest health care system in Central Massachusetts, shared how her organization operates on an escalation model. If a patient’s need is urgent, the case goes directly to a social worker; otherwise, cases are handled by a medical assistant. If the social worker determines the patient’s need to be beyond their scope, they will pull in the complex care management team which includes a nurse care manager, care coordinator, and social worker. What would a Medical Assistant (MA) address vs. a social worker (SW) vs. complex care team. See the examples below!

  1. Medical Assistant Example – a patient is worried about losing housing, but the situation isn’t imminent. In this example, there is an electronic resource for staff to expertly search for available resources by patient zip code. If an electronic referral is appropriate, the MA would move forward.
  2. Social Worker Example – a patient doesn’t have a home to go to or is sleeping in their car, a couch surfing option will no longer be available as of that day for the patient, or a patient has less time-sensitive needs yet limited capability for self-management.
  3. Complex Care Team Example – a patient with extensive inpatient stays has recently been released back into the community and is failing. The complex care management team will be pulled in to assist and surround the patient with resources.

PatientPing Pro Tip: Identify the patient’s provider and/or care coordinator by going to the Care Team section of the patient profile. For help clarifying the patient’s zip code or contacting difficult to reach patients, check the demographics at the top of the profile. Here, we surface all previously collected phone numbers from prior patient events so that you’re able to successfully connect with patients to coordinate care.

Making the Case for Investment in Resources to Focus on Populations Faced With Social Determinants

Henish Bhansali, MD, FACP, Senior Medical Director of Care Navigation at Oak Street Health, shared insights into the importance of investing in resources which focus on highlighting populations faced with social determinants. Dr. Bhansali suggested demonstrating that attention to social determinants can lead to decreased unnecessary hospitalizations. One way this can be done is by looking into ER visits and subsequent escalations of care – i.e. hospitalizations for inpatient or inpatient observation. For Oak Street Health, an average hospitalization costs approximately $20,000. 3.5 reductions in hospitalizations is approximately the average salary of a medical social worker (MSW). If the implementation of a MSW in the care model can reduce hospitalizations by 3.5 in a given year, the investment pays for itself. A way to further quantify this is by looking at the number of ER visits reduced, which can be calculated easily through PatientPing. Given a certain hospital’s ER to inpatient admission rate, an approximation can be made on cost savings based on ER visits.

PatientPing Pro Tip: Create a Ping Feed filter and set up real-time alerts for patients who present to the ED or are admitted to the hospital. The text and/or email notifications can activate real-time engagement with the patient and/or their care team to discuss lower levels of care, where clinically appropriate.   

If you have questions on how to set-up any of the PatientPing Pro Tips, feel free to reach out to the PatientPing support team!

Thank you to all those that joined and participated in our session. Though we found that there is no one stop solution to alleviate social determinants, we appreciate our community of leaders who shared approaches they have developed to help patients receive the care they need and overcome the challenges they’ve faced. 

 Stay tuned for our next roundtable learnings update coming in 2020!