Published on February 24, 2020
Teachers are often evaluated by how well students perform on standardized tests. Yet so many factors driving student performance are beyond their control. Are students properly nourished? Do they have stable home lives and safe communities? Are they suffering from trauma or abuse, or facing emotional and psychological challenges? Do they have ready access to the Internet? The list of influential variables outside a school’s four walls can be daunting.
Doctors and nurses face similar challenges. Only 10% of health outcomes are shaped by clinical interventions, while 60-80% are determined by Social Determinants of Health (SDoH) related to a person’s local environment, economic conditions, lifestyle, and behaviors. As providers and payers take financial risk based on the health outcomes of patients and populations, how can they influence factors that are beyond their control?
Management guru Peter Drucker famously said, “If you can’t measure it, you can’t improve it.” But healthcare’s first order of business is to identify what “it” even is. SDoH may be a trendy topic, but few people know how to weigh different variables, how to identify who is most at risk in a population, and how to determine which interventions will have the biggest impact on downstream health outcomes.
That’s why Carrot Health developed the Social Risk Grouper (SRG)™. Much like a FICO score that measures an individual consumer’s credit risk, SRG scores every adult in the United States according to their estimated individual SDoH risk.
SRG is based on consumer data variables that are curated in four broad categories – behavioral, economic, social, and environmental – and weighted according to their downstream impact on health. Notable SRG factors include loneliness, housing instability, food insecurity, transportation challenges, and lack of social acculturation.
These forces have a complex influence on health. For example, housing instability may mean a person lacks a permanent and safe living environment. But it can also involve the presence of health risk in the home environment, such as lead paint, mold, radon, or inadequate heating or cooling. Whatever the causes of housing instability, people with that challenge have a 37% higher ED utilization rate, according to data collected by Carrot Health.
SRG scores can be used to assess risk at the national, state or county level, and also to conduct a more granular analysis of specific neighborhoods, streets, and even individuals. For example, when we look at aggregate SRG scores nationwide, we see a pattern of higher SDoH risk in the southern states, especially in counties that border Mexico. In contrast, the North, Northeast and Midwest exhibit lower levels of risk overall.
Carrot SRG Score – United States, County-Level
Healthcare delivery and SDoH challenges are highly localized, however. It’s useful to drill down on individual communities to see where and how the variation in risk plays out. Let’s look at Dallas-Fort Worth, the fourth largest metroplex in the country, comprising 13 counties.
DFW is, in general, a vibrant and prosperous metropolitan area. It has the third most Fortune 500 companies in America, the fourth largest economy, and professional teams from every major sport. Yet, DFW also straddles extremes of health and social determinants. Smoking and alcohol consumption is high. Divorce rates are low, but alimony can be legally difficult to access. Sun exposure is hard to avoid, leading to higher incidences of skin cancer. Water quality varies greatly by neighborhood.
Looking at DFW through an SRG lens, it’s readily apparent that high SDoH risk is concentrated in the southeast of the metroplex. But there are pockets of high risk within generally lower-risk regions, and vice versa.
Carrot SRG Score – Dallas/Ft. Worth, ZIP Code-Level
Using SRG data, a health system, multi-specialty physician practice, or insurer can view the risk profile of a specific community and assess the level of risk at play to identify resources that may be helpful. If transportation needs are high, would urgent care clinics within walkable distances make a big difference? If the community exists in a food desert, would a food pharmacy improve overall health?
At the individual level, SRG scores can potentially transform the quality of care that physicians or nurses provide. A clinician with access to a patient’s SRG data can have more focused conversations about the factors in a patient’s life that will make a meaningful difference on their health. Perhaps the patient suffers from loneliness or needs a ride to their weekly doctor visit. If so, the clinician can support or put into motion appropriate and effective interventions. For example, a social worker could encourage a patient to join a community group or a patient might be given an online account to hail a Lyft and get to appointments more easily.
Like teachers with their students, clinicians know intuitively that overall health status has more to do with what happens outside the clinic or hospital than inside. Yet as care needs become more complex, care delivery becomes more costly, and the pressure of accountability for health outcomes intensifies, providers and payers will need robust consumer data to understand the real health risks that patients face so that they can allocate resources accordingly.
SRG scores are dynamic. In other words, as underlying SDoH risk factors change over time, SRG scores will change too. This means that SRG can provide benchmarks that community stakeholders can use to monitor progress and improvement. In turn, this can lead to more targeted interventions with more demonstrable ROI.
Edwards Deming once said, “In God we trust. All others must bring data.” The infusion of data-driven insights into care management will have a profound impact on the health of all Americans and the prosperity of our communities.