Pop Health 2: Measuring and Reporting on Social & Behavioral Determinants
What drives good population health?
Social, environmental and behavioral determinants determine 60%-80% of health outcomes.
The Robert Wood Johnson Foundation has been doing research to look in depth at these causes, to measure them, to report on them and ultimately to make recommendations to improve them.
In the rest of this post we’ll be looking at how data is collected on social and behavioral determinants of health and how it is reported.
We still have a bunch to cover about population health, and the next post will be on managing population health.
Data
Financial incentives from VBC payment models rewards improving health through cheaper interventions, such as the social determinant and behavioral determinants listed above. But, it requires good data on health of population.
Traditionally, the US has been good at tracking data on things like mortality and quality of life.
But tackling population health benefits from gathering data on a whole new set of determinants. Some of the determinants for which we have less good data include:
Bathing
Hygiene
Toilet hygiene
Transportation
Self-feeding
Below we’ll talk about some surveys that can help us gather data about these social and behavioral determinants.
Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
PRAPARE is a survey to assess a person’s social and behavioral needs. It can be found at this site and includes questions on:
Housing
Employment
Education
Security
Transportation
Social integration
Stress
Incarceration history
Domestic violence
Refugee status
American Academy of Family Physicians: The everyONE Project Neighborhood Navigator
The EveryONE Project Toolkit contains questions about
Housing
Food
Transportation
Utilities
Personal safety
Need for assistance
CMS Accountable Health communities project: Health Related Social Needs Screening tool (AHC- HRSN)
This one also contains questions and tools around:
Housing instability
Food security
Transportation needs
Utility needs
Interpersonal safety
Health Outcomes Survey - HOS
Health Outcomes Survey HOS is part of HEDIS and also measures some of the social and behavioral determinants of health.
CDC Healthy Days Measures
The CDC Healthy Days Measures asks a short set of questions, and measures how many days in the past 30 you have had good health and mental health.
The healthy days symptoms module, consisting of five questions related to symptoms that keep someone from daily activities.
When used with the four core healthy days questions, these 14 questions comprised the full CDC-HRQOL-14 measure
A 20 question guide to a broader definition of quality of life across areas like
Health practices
Household stability
Communication safety
Managing time,
Nutrition,
Relationships,
Alcohol and drug use
Sexual health and behavior
Personal care and hygiene
Reporting on Social and Behaviorial Determinants of Health
County Health Rankings
One of the best reporting systems on the Social and Behavioral determinants of health is the County Health Rankings from the Robert Wood Johnson Foundation and the University of Wisconsin. It can be found at www.countyhealthrankings.org
Here, you can look up counties across the US and see its rankings across a range of measures of reported outcomes. Below you can see a all the measures that you can see reporting on for any county across the US:
Additional Resources:
Social Determinants of Health Data Issue Brief. https://populationhealth.humana.com/resources/policy-brief-social-determinants-of-health-data/ Download the Issue Brief to review an examination of the types of SDOH data, considerations for healthcare use, current efforts to operationalize this data, and business impacts. Manchanda, R. (2014). What Makes Us Sick? Look Upstream. https://www.ted.com/talks/rishi_manchanda_what_makes_us_get_sick_look_upstream Dr. Manchanda discusses the factors that make people ill - like poor diet, a stressful job, and a lack of fresh air in this TEDSalon NY talk.