Social determinants of health (SDOH) continue to influence quality improvement efforts across the healthcare system, with a Virginia health plan and health system using the data to improve nutrition and even provide mobile vans to take services into the community.

SDOH data can be obtained through vendors and also through the health system’s own experience with patients, explains Thomas Lundquist, MD, MMM, FAAP, FACPE, senior vice president and chief medical officer with Optima Health, a health plan in Virginia Beach that is part of the Sentara health system.

“Both the health plan and the health system are increasingly capturing social determinants of health, and one of the things I look at is whether we should buy that data broken down by ZIP code or whether we should capture that information directly as our health system and health plan professionals interact directly with patients and families,” he says.

“The answer is that it should be a hybrid eventually because if we enter a new market, we can purchase access to a database that will show us what to expect on a ZIP-code level and maybe even by street. And once we’re in there a while, we develop our own data as we interact with them and determine what needs and limitations they have.”

One initiative that used SDOH within the Sentara health system is providing mothers with easy access to federally funded support programs, Lundquist notes. The traditional enrollment process for the federal supplemental nutrition program for Women, Infants, and Children (WIC) requires mailing the request for assistance, but in an effort to eliminate any potential travel barriers and also to expedite the request for assistance, a Sentara hospital employee facilitates the sign-up process at the new mother’s bedside.

“We find ourselves increasingly prescriptive when it comes to traditional social services outreach, encouraging members to enroll in WIC and to allow us to facilitate assistance with their utilities and housing,” Lundquist says. “We can only do that when we have that social determinants of health data. That requires us to have a care management system and an electronic record that captures that data and allows us to dive more deeply into details such as whether you live in a one-story or two-story home, whether you have carpet on your stairs.”

In addition, through a partnership with local food banks, Optima Health executed a program that provides new mothers with healthy meals following discharge from the hospital. It currently serves approximately 50 mothers per month with two meals a day for 90 days postpartum.

Optima Health also has worked closely with Sentara to proactively involve and engage community members, Lundquist says. Optima Family Care and Optima Health Community Care, both Medicaid programs for those with low income and disabilities in Virginia, implemented a statewide initiative called the Health Education and Awareness Program to encourage healthy living and lifestyles among youth.

Lundquist notes that lack of access to transportation also has been determined to be a barrier in receiving healthcare.

Optima Health partnered with organizations such as The Health Wagon in rural Appalachia, which provides mobile health vehicles for medically underserved communities in Virginia to deliver essential, free health services, such as mammograms and flu shots.

It has been an effective means of providing compassionate, quality care to rural communities with limited access to services, Lundquist says.

“The biggest challenges are prioritization, how to reach the services people need, and deciding what should be under our purview to pay for versus just connecting people to community resources and hoping for the best,” Lundquist says. “We’re evolving our systems to better capture the social determinants of health data … so that the nurse working with the patient can connect the dots in the moment and put things in motion more efficiently.”