Health is more than just healthcare. Research has shown that 80% of a person’s health is tied to their social determinants of health (SDOH), such as housing, employment, food, water, and many other factors. SDOH is at the core of the U.S. Department of Health and Human Services (HHS) long-term initiative, Healthy People 2030, and the Centers for Medicare & Medicaid Services (CMS) Framework for Health Equity, raising awareness and urgency around how our environment primarily affects health. Yet, the practices of screening for SDOH factors, not to mention the sharing of clinical and social data, lag behind the insights of research and the intention of policy.

Yet, in recent years, health information exchange (HIE) organizations have developed to meet important electronic health information needs beyond patient care. While progress has been made in healthcare data interoperability and information sharing, a much greater effort is required to support all community members, particularly the most vulnerable individuals, through integrating clinical and social care data.


The CMS Framework for Health Equity

The Centers for Medicare & Medicaid Services (CMS) has introduced a new framework to enhance health equity, broaden coverage, and improve health outcomes for over 170 million individuals benefiting from CMS programs. The framework presents an integrated approach to incorporating health equity into CMS initiatives and emphasizes SDOH's crucial role in achieving health equity and reducing disparities.

The CMS Framework for Health Equity outlines five key priorities for reducing health disparities:

  1. Expand the Collection, Reporting, and Analysis of Standardized Data: CMS aims to improve the collection and use of comprehensive, interoperable, standardized individual-level demographic and SDOH data.
  2. Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps: CMS is committed to assessing its programs and policies for unintended consequences and making actionable decisions about policies, investments, and resource allocations.
  3. Build Capacity of Healthcare Organizations and the Workforce to Reduce Health and Health Care Disparities: CMS supports healthcare providers, plans, and other organizations that ensure individuals and families receive the highest-quality care and services.
  4. Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services: CMS is committed to enhancing language access, promoting health literacy, and providing culturally tailored services to ensure equitable care and coverage for all individuals.
  5. Increase All Forms of Accessibility to Health Care Services and Coverage: CMS is dedicated to improving access to healthcare services and coverage for all individuals, regardless of their circumstances.

The framework establishes a foundational roadmap with SDOH data at its core to support healthcare organizations, professionals, and partners in achieving better outcomes and health equity.


The Shift Towards Social Care Data Integration

While the framework creates a foundation, only collecting and sharing SDOH data can change the practices that equitably improve healthcare outcomes. Introducing new data standards and policies supporting the collection, exchange, and use of SDOH data in health IT systems has redirected state-level initiatives toward enhancing existing data infrastructure beyond clinical data exchange.

Some Health Information Exchanges (HIEs), such as the Georgia Health Information Network (GaHIN), have started working towards integrating social care data with clinical data to support whole-person care. To better address community needs and social determinants, HIEs have a critical role in accelerating change by involving more health and social services ecosystem stakeholders to establish the necessary foundational elements for data exchange.


What Integrated Clinical and Social Care Looks Like

Integrating social and clinical data is critical to a whole-person care approach. Let’s consider “Janelle,” a Georgia resident, to illustrate:

Janelle visits a healthcare provider about a health condition for which she seeks treatment.

The clinical staff performed an SDOH screening during her intake and learned that she needs housing.

This data is sent through GaHIN to a referring agency, which forwards a referral and essential housing data to a community organization.

Janelle then contacts the organization to explore housing resources. The organization accesses her SDOH data from GaHIN and communicates the referral outcome to the agency.

The agency and the organization can track housing updates and coordinate care through GaHIN.

When Janelle revisits her provider, they can access her clinical and SDOH history via GaHIN, understand her housing situation and current needs, and refer her to appropriate services to put her in the best position to follow her treatment plan.

This coordinated, informed whole-person care scenario is becoming increasingly real due to concerted efforts at various levels, including federal, state, HIE, provider, and CBOs.


Integrating Social Care Data with GeorgiaUnify

As a result of our efforts, this scenario is becoming a reality. GaHIN now has a new social integration platform, GeorgiaUnify, designed to facilitate referral and coordination of services for effective whole-person care throughout the community. Despite the increasing awareness of how SDOH influence the health and wellness of individuals and their communities, there is a gap in most communities across the country. Health and human services are delivered in silos, making it difficult to provide coordinated, person-centered care and to assess the effectiveness of services. Initiatives such as GeorgiaUnify are creating change to ensure that outcomes improve through enacting whole-person care so that policy becomes a reality for the individual in their healthcare journey.

The Future of Whole-Person Care

The focus on SDOH data aims to improve whole-person care and outcomes by shifting from treating illness to promoting lifelong health. Integrating clinical and social data will enhance access to services and care outcomes. We are moving from solely sharing clinical data among healthcare providers to being able to exchange and integrate clinical, claims, social, and behavioral data. This will support various aspects of care, including treatment, care management, coordination, quality improvement, population and public health, and more.

Integrating clinical and social data is not just a trend but a necessity in today’s healthcare landscape and for equitable healthcare. As we continue to understand and acknowledge the importance of SDOH, we must strive to create systems and processes that allow for the seamless integration and utilization of this data to provide truly holistic, whole-person care.