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3 insights on advancing health equity through social determinants  image

3 insights on advancing health equity through social determinants

Estimated read time: 3 minutes

by Cerner Corporation

Published on 12/14/2021

COVID-19 has highlighted healthcare disparities that have existed for far too long. As we push for health equity, we must address the key social determinants of health (SDOH) that play a significant role in a person’s well-being and quality of life – economic stability, access and quality of education and healthcare, neighborhood and built environment and social community context.

Danny Gladden, MBA, MSW, LCSW, director, behavioral health, Cerner, joined Priya Bathija, vice president, strategic initiatives, American Hospital Association, at the 2021 HLTH conference to discuss actionable approaches health systems can take to address the non-clinical barriers that impact health equity. Here are three key takeaways from the conversation. Scroll down to watch the interview recording.

1. Data is the starting point
Danny points out behavioral health screening tools within the electronic health record (EHR) that enable providers to capture accurate data in near real-time to make more informed patient care decisions.

Hear Danny discuss why health systems should apply the same approach to assess SDOH risks as early as possible.

In addition to supporting intervention, Danny explains that data can also help providers make connections, such as the link between suicide risk, depression and other chronic illnesses.

“Collecting data at the micro level helps a hospital to make decisions about the type of care it’s going to provide. What we learn from the data begins to shape hospital and community policy. The data helps us understand where we have a high density of need and a lack of services within the community.” – Danny Gladden

Health systems can use data to back healthcare reform initiatives, such as funded Medicaid expansion, and other efforts that help improve community health, including better employment opportunities and affordable housing.

Danny suggests we all must use data to inform organizational policy and to advocate for policy change at the local, state and federal levels.

2. Social care must be prioritized

Evaluations that consider the biological, social and psychological aspects of someone's life to determine the cause of their problems are standard in behavioral health. According to Danny, these assessments should be an essential part of all care settings.

“We assess for housing and food insecurity. We want to understand the person’s relationships and trauma history. We want to understand their proximity and access to healthcare and primary care. You can’t treat a person’s health without ensuring they have a safe place to lay their head at night and they aren’t hungry.” – Danny Gladden

Danny encourages healthcare providers to ask patients questions around food and housing insecurity during the intake process and to be ready to support those in need.

“Having a referral system in place or using your data to inform investment into your own care system can help push folks along in the housing and food space. If we want to stop the revolving door in our hospitals, we must treat the whole person, which includes social determinants of health, mental health and addiction.” – Danny Gladden

3. Community-level intervention is critical
Proactive relationships between health systems and the community’s broader human service delivery model can be a game-changer. Danny says data-driven insights should be integrated into health IT to help providers identify those who might be at risk for mental health conditions, food and housing insecurity and other issues before they enter a care venue. He suggests that health systems use customer relationship management technology to run marketing campaigns that target at-risk populations for early intervention.

“We have a good handle on where to go within the four walls but getting out ahead of an individual’s first interaction with the hospital is critical.” – Danny Gladden

Watch the Interview below.


Cerner Integrated Behavioral HealthTM earned a 2021 Best in KLAS award. Click here to learn more.

Cerner Determinants of Health aims to provide health systems, payers and Medicaid agencies with insights into factors that can advance health equity. Click here to learn more.

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