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 will focus on approaches to establishing effective SODH screening practices across the care continuum and establishing flows of information across the ACO to identify social needs, make referrals and track outcomes. It will also discuss the use of “z-codes” for potential reimbursement of SDOH services and strategies for moving from identified needs to targeted initiatives. This session will also touch on utilizing types of third-party data that are available and ways to leverage them.