Over the last few months, we’ve published several blogs that share vital, timely information about Social Determinants of Health (SDoH), social needs, and how the ACG System has the ability to take this raw data and transform it into usable metrics for developing a population health plan.

Today, we’re sharing an article from Elham Hatef, MD, assistant professor of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. Dr. Hatef explains how organizations can greatly benefit from the ACG System’s social needs functionality, and the meaningful health improvements patients can see as a result.

Distinguishing Between Social Needs and Social Determinants of Health

Put simply, social needs affect an individual, while SDoH impact an entire population. For example, literacy is a social need that affects a person’s ability to read. However, lack of education is a SDoH where a large population may only have an elementary education level. Literacy is an immediate need that impacts daily life, while lack of education is something that may negatively impact a community over the course of their lifetime.

Putting Social Needs Data to Work

Social needs data can provide a lot of information about how a person lives, but in order to harness that information, it’s critical to correctly capture that data. The ACG System collects information sourced through patient portal surveys and EHR forms, creating documentation to show the needs of a patient population. That information can then be used to develop clinical care delivery models that help address social needs at the lowest level.

Within EHRs, ICD-10 Z-codes are incredibly helpful for standardizing documentation about a patient’s immediate needs. These Z-codes more specifically identify the impact social factors have on a population, and help drive a more effective response from community-based organizations.

The Value of Social Need Markers

As we’ve discussed, an individual’s health is directly impacted by their social needs. Providers and care management teams need this information to best care for a patient population, but there are occasionally gaps in capturing the data: some EHR vendors don’t offer the capability to track this information in dedicated fields, while the data that is tracked often isn’t suitable for analytics.

For example, a patient with immediate social needs may be more likely to be readmitted after discharge. Preventing readmission requires accurate and comprehensive data on that individual’s social needs – now available via the ACG System’s Social Need Markers and ICD Z-Codes, users can begin to identify these individual patients and intervene quicker than before.

Proactively developing successful interventions for a community reduces overall health care costs and increases life expectancy. The ACG System is useful for any health organization or payer with a goal to build a healthier community. For more information and to read the full article from Dr. Hatef, click here.