WEBINAR | Developing an Analytic Process to Help Address Social Drivers of Health at The MetroHealth System

Nabil Chehade, MD, MSBS, Interim Chief Executive Officer; Executive Vice President, Chief Population and Digital Health; James Misak, MD, Assistant Professor, Institute for H.O.P.E.; and Kevin Chagin, MS, Manager, Advance Analytics & Data Operations, Institute for H.O.P.E., The MetroHealth System. The Greater Cleveland area has some of the best health care institutions in the world. Yet it also has some of the worst health outcomes across its population. In 2022, Cuyahoga County ranked 11th, out of 88 counties, for clinical care and 82nd in quality of life and social factors. Across two local ZIP codes, just five miles apart, residents have a 23-year difference in their life expectancy. In 2019, The MetroHealth System’s Institute for Health, Opportunity, Partnership and Empowerment (H.O.P.E.TM) was founded to identify social drivers of health (SDOH) within the MetroHealth patient population and to address health-related social needs.

MetroHealth has developed an approach to understand the SDOH impact on their patient population, e.g., who is at risk, what risks are being experienced, and how these risks impact medical comorbidities, treatments, and hospital utilization, starting with a screening process organized through their Institute for H.O.P.E.TM and using a variety of means: community health workers, social workers, and care coordinators; in person or via a paper-based or electronic interface at the point of care; through secure online health management tools (MyChart); and at hospital events (i.e., COVID vaccine clinics and the Minority Men’s Health Fair). These screens were then merged and connected to patient demographics, geospatial location, healthcare characteristics (primary care location, payer status, etc.), comorbidities, clinical and laboratory data, hospital utilization data (ED visits, hospitalizations, appointment no shows, etc.) and publicly available data (US Census), and a dashboard was created to highlight key findings and tell the story of how SDOH impact the community. Join the MetroHealth team to learn more and to hear how these processes are generating insights to support novel research protocols, support funding of pilots and programs, and inform decisions on effectively addressing the social needs in their patient population.