Social Determinants and the Impact on Risk Stratification and Care Delivery: A Look at Prince George’s County Health Department

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Prince George's County Health Department partnered with HealthEC in 2016 to begin to collect, analyze and use the data from an assessment for social determinants of health (SDoH) to change the department's approach to population health within their community.

HealthEC was able to help Prince George’s County Health Department in a number of ways, including:

  • Incorporating an SDoH Assessment questionnaire into a population health platform
  • Aggregating patient data from multiple sources to provide a comprehensive view of clinical and statistical data to care coordinators
  • Identifying patterns in care delivery and resource utilization across multiple programs and data sources
  • Integrating data from the Chesapeake Regional Information System for all Patients (CRISP)
  • Assisting in the prioritization of the top 10 percent of its patient population that represented 80 percent of hospital readmissions and non-urgent emergency department visits
  • Incorporating data from the Prince George's County Public Health Information Network to provide instant access and distribution of patient information to all authorized providers involved in patients' care
  • Combining the use of social determinants of health assessments and disease-based assessment tools to identify barriers to accessing care and subsequently reallocating resources to the patients with the greatest need

The results?

  • Prince George's County Health Department’s work to reduce hospital readmissions has been documented to save one hospital more than $1 million within one year of deploying this solution across their care coordination team.
  • An 8.6 percent reduction in overall hospital utilization for dual-eligible Medicare patients, based on Medicare Part A claims.
  • Providers now have access to the most up-to-date information about patients, which improves the ability to identify care gaps, provide effective care coordination, and support care transitions.

 

HIMSS19 Lets Meet Banner

Sanjay Seth, MD
Author: Sanjay Seth, MD
Date of Publishing : 11/6/18 4:30 PM
About the Author : Sanjay Seth, MD, is executive vice president at HealthEC. With over 30 years of clinical, administrative and consulting experience, Dr.Seth is uniquely positioned to develop population health management strategies that support healthcare providers and organizations.
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