Using Social Determinants to Promote Health Equity During a Crisis

May 22, 2020 - Across the healthcare landscape, it is widely understood but rarely confessed that not all care is delivered equally. 

In an ideal world – or just a fairer one – the medical industry would be able to seamlessly address an individual’s clinical and social needs, providing the comprehensive care necessary to ensure positive outcomes for every patient.

In reality, this is not always the case.

Interoperability issues, poor care coordination, and a lack of funding has hindered social determinants of health data integration, leading to gaps in care and health disparities for individuals and whole communities.

With the sudden onset of COVID-19, these gaps and disparities have only grown wider. Individuals living with chronic disease, people in underserved areas, and minority populations have been hit the hardest during the pandemic, highlighting underlying issues that have plagued the industry for years. 

Research recently published in JAMA showed that hypertension, obesity, and diabetes are key chronic conditions in the acuity of the virus. In another study, a team from the Commonwealth Fund revealed that COVID-19 is more prevalent and deadly in US counties with higher black populations.

When examining research like this, one thing is clear: The rapid, global spread of the virus is certainly unprecedented. The disproportionate impact it has had on certain populations, however, is not.

“There has been a fair amount of conversation about COVID-19 being an equal opportunity killer. But frankly, that’s just not true,” Helen Dowling, MPH, data in action coordinator for the Public Health Alliance of Southern California, told HealthITAnalytics.

“There are communities that are dying at much higher rates than others, and it’s really important that we look at the data, spell it out by race and ethnicity, and focus on how we can improve the communities where these individuals live.”

To reach these goals, stakeholders across the care continuum are coming together to find new ways of sharing data, developing solutions, and addressing health disparities. 

Collecting the data that matters, where it matters

Before healthcare leaders can understand how to help the specific people and places most impacted by COVID-19, they first have to access the information that will tell them who and where these individuals are.

For many health systems, this is no small task. 

Data privacy and security concerns, insufficient infrastructure, and the industry’s longstanding data sharing challenges are all major barriers to accessing social determinants information, leaving stakeholders without the data necessary to make meaningful impacts.

The coronavirus outbreak has only exacerbated the issue. When dealing with a health crisis of this magnitude, there are bound to be challenges with gathering and capturing data, and gaps in information will more likely be the norm than the exception.

“Overall, data on COVID-19 is limited. Every time you face something like this, that hits individuals around the globe, there’s always a shortage of data that is made publicly available,” said Jennifer Hall, PhD, chief of the American Heart Association (AHA) Institute for Precision Cardiovascular Medicine. 

“Around the world, everyone is facing that challenge – to find deep data that involves clinical variables, as well as different variables around race and health disparities.”

To expand the resources available to researchers, AHA recently launched a data challenge to address how COVID-19 is disproportionately affecting those in underserved communities.

As part of the challenge, AHA is making global COVID-19 datasets available on its Precision Medicine Platform, which allows researchers from all over the world to partner and access critical information. Teams can use datasets hosted on the platform as well as their own data to examine the relationship between COVID-19 and health disparities.

“Through this cloud-based platform, researchers have a secure workspace with tools and software programs available to them, and they can collaborate with others as well,” said Hall.

“Especially in times like today, where researchers are not in their classic environments, it’s extremely important that they can access standardized data through their desktop computer.”   

In the public health sector, adjusting to non-traditional work conditions is especially challenging. Local health agencies, care management services, and community groups may not be able to support vulnerable populations in the ways they are used to, resulting in less effective interventions and poorer outcomes.

For leaders at LifeBridge Health, a provider organization serving the Greater Baltimore region, cross-sector partnerships were the solution to this problem. The health system has convened a statewide Taskforce on Vulnerable Populations for COVID-19 in Maryland, using a data-driven approach to identify high-risk communities and individuals. 

Led by Susan Mani, MD, chief population health officer at LifeBridge Health, the taskforce is leveraging information from multiple sources to develop a COVID-19 risk index for severe outcomes.

“We recognized that we needed to come together as a coalition to figure out how to shift into this home model so that we could deliver the kind of care and resources that were needed,” said Mani. 

“We were able to get robust information from many of our stakeholders and overcome some of the traditional barriers that might exist in gathering the data that you need to do the most effective map around vulnerable populations.”

Through partnerships with state-based organizations and data analysts, LifeBridge Health was able to access data on community disease burden, population density, individuals’ chronic disease history, and other factors to determine COVID-19 susceptibility. 

“It’s become this incredible wealth of information that we’re constantly looking at and trying to add even more information to as we think of greater use cases for it. It’s really taken on a life of its own,” Mani said.

On the West coast, public health organizations are also gathering social determinants data to identify vulnerable populations during the pandemic. The Public Health Alliance of Southern California recently released an interactive COVID-19 Healthy Places Index (HPI) Resource Map on the California HPI platform. 

The resource map serves to support local response efforts and promote health equity during the pandemic. 

“The reason we developed the Healthy Places Index in the first place was to help the allocation of resources to disadvantaged communities,” said Dowling. 

“Our COVID-related indicators are from publicly-accessible sources, and we made sure to pull the indicators that we thought would be of the highest interest. Those include elements like COVID-19 deaths by race and ethnicity, as well as vulnerable population data, like seniors with disabilities, non-white seniors, and outdoor workers.”

Using census-level information and open datasets from public health agencies, the organization was able to develop a comprehensive map that shows the equity implications of the pandemic. 

“A lot of the data is out there. It was just a matter of pulling it together and putting it all in one place,” said Dowling.

Pinpointing the who, what, where – and why

In the midst of a widespread, rapidly evolving crisis like COVID-19, it isn’t enough to have data at just the state or even the county level. 

In order to improve outcomes in vulnerable populations, healthcare leaders must first meet the needs of the individuals who comprise those populations. This will require organizations to take a magnifying glass to their big data assets, allowing them to see the finer features that form the whole picture.

“A lot of tools show the distribution of COVID-19 cases and deaths, but there aren’t many that go to the level of detail to provide information about all these community conditions that could exacerbate the virus,” said Dowling.

“That’s why our map goes down to the census tract level, because even county-level information can obscure a lot of the variation among communities. In Los Angeles, you can be within a 20-minute walk of some of the richest communities in the state and some of the very poorest, by community conditions. And it’s just a couple of miles. You don’t see that if you’re looking at data at a higher geography.”

Maryland’s taskforce is drilling down its efforts to a similar degree of granularity. 

“By each of the jurisdictions, you can get a general sense of the level of risk within their communities. On our risk scale, a score of one is little or no risk, all the way up to severe risk – that would be hospitalization, requiring the ICU, or potential mortality from COVID-19. Anyone with a score of three or greater is considered elevated risk,” said Mani.

“This allows us to map those communities down to a zip code level, or down to a street level.”

Recognizing where exactly the disparities lie can help officials get ahead of negative health outcomes, Mani noted.

“One county took a look at the map and said, ‘Ah, I can see that on the eastside and westside we have these areas of elevated risk.’ They already have connections with their homeless shelters and some of their elderly congregate facilities in these areas, so the map enabled them to target their outreach efforts to those facilities,” she said.

For AHA researchers, eliminating health disparities during COVID-19 and beyond means not only recognizing where and whom the virus is hitting the hardest, but also uncovering the root causes of severe illness. 

“We hope to see many different types of solutions from this data challenge, from any of our three focus areas. The first being, how is COVID-19 affecting patients with cardiovascular risk factors differently? Why are these individuals at greater risk, and how can we solve that problem?” said Hall.

“Secondly, we’re trying to understand why individuals with health disparities are at greater risk of the virus. We’re also conducting research on why those with certain social determinants of health are at greater risk for poor outcomes from COVID-19.”

Translating big data resources into tangible interventions

On the long, often difficult trek toward health equity, data access is just one small hill at the base of a larger mountain. Once stakeholders have the information they need, the next step is to develop measures that will lead to improved health outcomes.

Southern California’s Public Health Alliance developed its COVID-19 Resource Map with this critical point in mind, Dowling noted.

“We wanted to make sure that each of our indicators were actionable for policy. You can look at an indicator on the map and then have policies associated with that indicator to actually improve it,” she said.

“For example, public health departments might be interested in looking at areas that have high concentrations of obesity and diabetes so that they can direct testing resources to those areas. Or if you’re in transportation and planning, you might be interested to know who relies on public transit to get around, so you can better understand how to support those individuals.”

Leaders participating in Maryland’s taskforce were also sure to make the jump from data collection to active intervention. 

After looking at the maps and seeing the volumes of communities at risk, Mani and her team recognized that they needed to create resources for some counties to conduct proactive testing, as well as remote health services. 

“We were hearing that because of the fear of COVID-19, there were a number of individuals with underlying chronic illnesses who were scared to go into hospitals, EDs, or doctor’s offices because they were afraid of getting the virus. But if people have chronic illnesses that aren’t being treated, that puts them at greater risk of getting severely ill from COVID,” Mani said. 

“We put together Testing and Manage in Place Teams, which consist of EMS providers and social workers. These teams can go into facilities – whether it be homeless shelters, assisted living facilities, at-risk neighborhoods – where there might be concerns about residents being able to access healthcare.”

The teams can conduct health screenings, connect individuals to social resources, and administer COVID-19 tests, Mani said. With this approach, stakeholders are targeting their efforts to reduce the burden on healthcare systems across the state.

“It’s looking at big data and taking that wider view all the way down to meet individuals’ needs. That’s really been incredible during this time,” Mani said.

At AHA, leaders are working to develop actionable solutions using COVID-19 data as well. In addition to its data challenge, the organization has awarded $1.2 million in grants to teams at 12 institutions who are studying the effects of COVID-19 on the cardiovascular system and underserved populations. 

“These grantees will also be using this data that we’ve opened up to add to the research that they’re doing,” Hall said. 

“We hope that these additional researchers will all come together to solve problems around social determinants of health, health disparities, and cardiovascular-related conditions in COVID-19.”

Implementing policies for lasting change

In the battle to control and track the COVID-19 pandemic, the healthcare industry has had to face some of its most enduring, burdensome issues – health disparities and inequities being some of the most notable among them. 

Rather than introduce new problems, the pandemic has brought underlying challenges to light, revealing the need for constructive, permanent change.

“We now recognize, with even greater attention, that we need to put more effort into predicting which individuals are most at risk. We need to prevent these individuals from contracting disease or dying from disease,” said Hall.

For Hall, an increase in research partnerships will be one of the most important changes. 

“We hope that some of these collaborative scientific groups that come out of this data challenge would continue to focus on these areas and building on those solutions,” she said. 

Mani also emphasized the significance of enduring partnerships, especially among different parts of the industry. 

“This data has been able to help us start thinking about the proactive targeting of resources and planning. The pandemic has also highlighted the need for more cross-sector collaborations to find new ways of addressing individuals’ needs,” she said.

COVID-19 may also bring much-needed changes that lead to more equitable systems outside of healthcare. 

“One of the policy changes I would really hope to see is more affordable housing. Housing is a key human right, and in many of our cities in California, it’s extremely unaffordable,” Dowling said. 

“We need to understand where these communities are and implement legislation to help people who can’t make rent or mortgage payments right now, or create more affordable housing for folks who just don’t have the means to afford what’s currently out there.”

It’s clear that the impacts of the pandemic will continue to be felt, long after the situation has subsided. The hope is that the industry’s calm after the COVID-19 storm is a little better than what it was before.  

“This pandemic is not a sprint. It’s a marathon,” Mani said. 

“This is going to have long lasting effects, both from a health perspective and an economic perspective. We have to start thinking about coming together and becoming greater than the sum of our parts.”