Session 2: Identifying SDOH Needs and Tracking SDOH Data at the Health System and Community Levels

Identifying the right beneficiaries to target for SDOH initiatives is key to closing care gaps and maximizing the benefit of limited resources. Doing so can be challenging in large organizations that include multiple care sites (hospitals, clinics, independent practices) with different methods for collecting and storing information and different information systems that may not share information easily. This session focused on establishing effective SODH screening practices across the care continuum and building an organization-wide information system to identify social needs, make referrals and track outcomes. It also discussed using “z-codes” in anticipation of future consideration of social factors in risk adjustment and for future reimbursement of SDOH services. The session also touched on the pros and cons of using third-party data to gain a better understanding of patients’ race and ethnicity and the potential for individual patients to face social risk factors.

SDOH Data and Tracking at the Health System Level
Presenter: Ashley Fitch, Director, Community Health Innovations & Partnerships, Mount Sinai Health System
Date: October 28, 2021
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Assessing the Social Risk Factors and Needs of Patient Populations: Considerations for ACOs