Using Social Drivers of Health to Reduce Admissions for Diabetes Patients, Among Others

Editor’s note: Madeleine McDowell, MD, Senior Principal, Sg2, contributed to this post.

As healthcare organizations face unprecedented workforce and financial challenges, much emphasis is placed on capacity constraints with rising acuity and regulatory scrutiny as powerful underlying trends. Many systems struggle to find the right balance between their margins and their missions, and often see their capacity realities outweigh their community’s health equity needs.

Or, if they’ve launched health equity initiatives, they flounder without the capability to identify and measure disparities effectively to sustain their initiatives.

To solve for this, in a recent study, we used the patent pending, publicly available Vizient Vulnerability Index™—a quantitative assessment of social drivers of health (SDOH) that influence a person’s overall health by providing a geography-based method for evaluating disparities that impact health down to the census tract level. We cross-walked the index by zip code with a combined five-state—Arizona, Florida, New York, Pennsylvania and Texas—all-payer 2021 inpatient dataset to identify geographical differences in hospitalization rates by social risk score for diseases and procedures.

In doing so, we were able to correlate social needs to inpatient utilizations so that healthcare executives can leverage the index to align initiatives addressing SDOH for communities with hospital challenges such as capacity constraints and accurately plan for inpatient bed demand.

  • 116 conditions were identified as “SDOH-sensitive conditions,” which have a strong positive correlation (R2>0.7) between increased hospitalization rate and Vizient Vulnerability Index score.
  • Patients residing in zip codes with high or very high social needs had significantly greater hospitalization rates (20% or more) for the 116 SDOH-sensitive conditions, which span chronic diseases, trauma, behavioral health, obstetrics and infectious disease.
  • Collectively, the conditions represented 71% of total hospitalizations, but the proportion increased sharply to 83% in high, and 94% in very high social needs zip codes.

Utilizing this approach, we took a close look at diabetes, one of the 116 SDOH-sensitive conditions studied. It became clear that organizations could make an impact by acting upstream to directly address SDOH to reduce preventable admissions in communities with needs. Here’s what we know:

Diabetes demand and acuity are rising: By 2026, there is a projected 12% growth for diabetes inpatient discharges and an 8% increase in average length of stay according to the Sg2 Impact of Change® Forecast.

SDOH is correlated to higher rates of inpatient discharges for diabetes: 14% of diabetes patient discharges came from zip codes with high social needs in our sample, and the inpatient discharge use rate for diabetes was 70% percent above the five-state average from those high social needs zip codes or 144% above the five-state average in very high social needs zip codes. The R2 Correlation between social needs score and diabetes admission rate was 0.97, signifying that 97% of the variance observed in diabetes admission rates by community was due to the level of vulnerability.

Acting upstream with prevention: Taking the high expected growth and high impatient use rate for patients in these communities, we can imagine a scenario where a Diabetes Prevention Initiative is launched, with a goal to reduce diabetes inpatient use rate by 20% in high community zip codes. Tactics could include targeting food insecurity and increasing diabetes self-management training—documented solutions for success—in communities of need. If successful, the initiative would yield an 8% decrease in the bed days for the market, which translates to $126M in potential bed day cost savings nationwide.

As with the Diabetes Prevention Initiative, healthcare executives can build a business case and develop targeted initiatives to address specific social needs at the zip code level to target capacity constraints related to conditions strongly correlated to social need in their markets. The following steps can help organziations take action on strategic decisions to make utilization improvements for diabetes patients—as well as for other conditions—by addressing SDOH:

  • Align the initiative with organizational goals: Reduce capacity constraints in hospital inpatient setting by preventing inpatient discharges correlated to social needs in high-needs communities.
  • Select disease target based on community needs: For 116 conditions, inpatient use rate is strongly correlated with the Vizient Vulnerability Index score.
  • Select relevant tracking metrics: Identify an appropriate data collection mechanism in collaboration with community stakeholders to track effects on patient populations.
  • Select a program or tactic to meet your goal: Collaborate with the community to select a program that impacts the selected and improves patient outcomes, such as community health worker-led diabetes self-management programs.
  • Evaluate and iterate: Analyze collected data and discuss impacts with key stakeholder groups. Iterate on tactics or metrics as necessary to maintain alignment with goals.

Utilizing the Vizient Vulnerability Index to identify root causes for patient hospitalization pattern differences allows healthcare organizations to prioritize targeted investments to address disparities. These investments are not only a win for the patients and community, but for the organization’s bottom line.

Learn more about this study at Kopaskie and McDowell’s poster presentation at the Institute for Healthcare Improvement (IHI) Forum Dec. 10-13.

Explore the patent-pending Vizient Vulnerability Index™, a public-facing resource for healthcare organizations to assess social determinants of health that impact health equity in communities they serve.

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