Leverage Social Determinants of Health to Build New Systems of Care
Social determinants of health (SDOH) are the social factors that produce or contribute to illness and other health conditions. They include poverty, homelessness, exposure to violence, and exposure to toxins. Tackling SDOH is a pathway to real population health management.
For over 35 years, Advocates for Human Potential, Inc. (AHP) has been improving health and human services systems of care and business operations to help organizations and individuals reach their full potential. Our expertise across health, behavioral health, and social services sectors, with a focus on special populations, enables us to approach SDOH in a way that helps you improve population health outcomes.
A Human Approach to Data
Leveraging SDOH data to develop the most effective clinical and social pathways requires information from
many different sources. AHP’s methods work to collect, aggregate, analyze, and report data from myriad sources. Our approach includes:
- Identifying and defining SDOH indices.
- Aggregating SDOH data and other critical data sets.
- Stratifying populations according to risk profiles.
- Developing systems, provider networks, and clinical pathways accordingly.
- Evaluating results and system performance.
Using these data, AHP helps develop systems of care appropriate to high-need, complex subpopulations.
Solving the Problem
AHP assists clients in addressing SDOH using a multifaceted approach that includes consulting and
training designed to:
- Increase understanding of SDOH in the context of population health.
- Identify and select SDOH that are locally relevant.
- Assess capacity and capability of Systems of Care to address SDOH.
- Adopt and implement SDOH tools and strategies based on criteria such as speed, cost, infrastructure and IT requirements, clinical operations, and reporting (contractual and value-based reimbursement [VBR] requirements).
- Develop data integration, analysis, and reporting.
- Expand capacity to correlate data and risk.
- Determine where gaps are and how best to fill them.
- Evaluate the success of these actions.
Why Now?
Addressing SDOH is critical to the national drive for increased value in health care. Providers and systems
are making changes toward VBR, population health, and health equity, all of which require addressing SDOH for their success.
Why AHP?
AHP has the depth and breadth of knowledge to meet the demands of system redesign focused on solving economic, educational, social, environmental, and health issues for the health of communities. This includes deep expertise in:
- Clinical and medical issues.
- Health Information Technology (HIT) and electronic medical records (EMR).
- Change management.
- Complex subpopulations, such as veterans, homeless individuals and families, and those with serious mental illness and/or substance use disorders.
- Public and health policy, managed care, finance and IT.
- The intricacies of “Big Data” management.
- Research, evaluation, and reporting.
- Project management and implementation.
- Training and technical assistance to bring concepts into action
When you address SDOH, you drive outcomes: make good on VBR, empower the provider network to serve the unique needs of the community and population, and ultimately support whole health and wellness.
About Us
Advocates for Human Potential, Inc. (AHP) creates powerful solutions to improve health and human services systems. By partnering with the federal government, states, municipalities, healthcare systems, and nonprofits, we help people experiencing the greatest disadvantages lead full and productive lives. We are national leaders in training and technical assistance, research and evaluation, publishing, and dedicated consulting. On issues from workforce development to mental health, substance use disorders to housing and homelessness, we help our clients enhance behavioral health care through systems change. AHP was founded nearly 40 years ago to develop solutions for some of the biggest social infrastructure challenges across the nation. Our company has offices in metro Boston, Chicago, and Los Angeles. Find out more at www.ahpnet.com.
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