Actions to Improve Social Determinants | EdjAnalytics

Actions to Improve Social Determinants

Actions to Improve Social Determinants

Bringing HLTH 2019 to YouA Three-part Blog Series from EdjAnalytics (Part Two)

By Susan Olson, PhD (EdjAnalytics COO)

In a three-part blog series inspired by HLTH, Edj is sharing perspectives it gained from the event. In part two of the series, the content focuses on actions to improve social determinants of patient health.

At the HLTH event, Barry Ostrowsky, President and CEO of RWJ Barnabas Health in New Jersey, may have best articulated one of the fundamental shifts in healthcare perspective when he said that RWJ changed its mission from “healthcare” to “health.” Ostrowsky described how the hospital has invested heavily in battling unemployment, resolving food insecurity and creating new housing. Another common discussion point from health systems was abandoning the term non-compliance and picking up language about breaking down barriers to health. In this blog, we focus on examples of how companies and organizations are breaking down two of those barriers to health: transportation and housing.


The “Odd Couples of Health” session at HLTH featured a panel with Dan Trigub[1] of Uber Health, John Gresham[2] of Cerner, and Craig Anderson[3] of Bay Care. Trigub kicked off the panel by revealing that Uber Health was integrating with Cerner. The integration will enable Cerner users to hail rides for patients as part of the EHR experience. Trigub described their HIPAA compliant platform and a partnership with 1,000 payers, providers, and technology partners.

Cerner, a $5.4B company, supports an ecosystem of 650 partners, including companies like Uber Health. Areas of partnership include: 1) platform solutions and integrations (e.g. AWS); 2) code development programs (e.g. Uber Health); and 3) the Internet of Things ecosystem (e.g. Zebra).

To provide a detailed experiential example, Anderson discussed the successes Bay Care has experienced from providing Uber rides to patients in need. Three benefits Anderson highlighted were: 1) improved patient experience; 2) faster hospital throughput because beds open up faster when patients were not waiting on cabs to be discharged; and 3) better outcomes. He referenced that the ride service reduced discharge time by 65 minutes. In the beginning, Bay Care used the service for hospital discharges and behavioral health discharges. Now they have broadened use into enterprise care coordination, including patient appointments. In 2019, he projected Bay Care would provide 22,000 rides to their healthcare consumers.

Anderson discussed that providers like the service because it improves patient outcomes and reduces no-shows. And the love from payers was clear too – Florida Blue provided Bay Care with a grant of $100,000/year for three years to provide rides to patients.

In other ventures, Allscripts partnered with Lyft back in 2018 and provided functionality for clinicians to order Lyft services for patients in the SunriseTM EHR.


At HLTH, Dr. Rhonda Medows of Providence St. Joseph wove a story of how Providence began in its roots to take care of people socially, to help the poor and the vulnerable. The health system recently developed its population health division, over which Dr. Medows now presides. Providence has partnered with Catholic Charities in its efforts to add 300 housing units to existing affordable housing in Portland, Oregon. The system also invested $5M into Plymouth Housing to create healthy housing around Seattle. These are only two of many investments Providence has made to combat homelessness. RWJ Barnabas Health, Kaiser Permanente and Atrium Health are other examples of health systems investing in affordable housing.

Dr. Medows said that for social determinants initiatives to work, an organization has to be aligned from top to bottom. She reminded the audience that there have to be real dollars set aside for capital and operating expenses. And she said that an organization’s incentive system also needs to be aligned, describing a program for performance where regional metrics roll up to the whole health system level to determine incentives.

In terms of ROI, Ostrowsky said that there wasn’t hard data on KPIs but that the system was seeing increased engagement. Dr. Medows discussed that metrics that matter are: how many people are served through the programs, how many longitudinal services are provided to a person, reducing length of stay, reducing readmissions and reducing unnecessary emergency room usage.

On the topic of ROI and better health from housing, the American Hospital Association published a case study that indicated a 67% drop in housing participants’ health care costs, excepting an end-of-life care case. There was also a 35% reduction in emergency department usage and an increase in participant access to routine care.

Two 2019 Launches in Louisville

There are numerous efforts in our own community to break down barriers to health, and two that launched this year are mentioned here. In April, United Community launched its innovative, shared data platform to connect businesses and agencies that address barriers to health. At its essence, the platform reduces barriers to access for people by putting care services providers in common touch. A counselor working with an individual to resolve one barrier can access services for additional barriers that need to be resolved. The counselor can use the platform to send out a signal across the platform for help with those other barriers. Not unlike the Uber driver system, those providers can then pick up the signal and offer to help.

To tear down food security barriers, Kroger, Dare to Care and Louisville Forward partnered to launch the Zero Hunger Mobile Market. The 44-foot long, single aisle grocery store on wheels makes two to three stops each weekday in locations that have limited or no access to fresh and nutritious foods. 

Learn how Edj is combining social determinants of health data with clinical data to transform how health systems reach patients and consumers.

[1] Head of Uber Health (after leaving Lyft)

[2] Senior VP at Cerner

[3] Director of Innovation at Bay Care

Read the full series: Bringing HLTH 2019 to You