Implementing smart strategies to improve community health requires understanding and targeting all of the social determinants affecting it, from economic and educational opportunity to housing and food security. That requires effective use of data, both to figure out precisely what the risks are and to create targeted interventions that will actually work.
That was the key message emerging from “Assessing the Power of Data to Track Community Health,” a webinar hosted by U.S. News & World Report as part of the virtual Community Health Leadership Forum that began last week. A panel of experts demonstrated the potential of data to identify risks in a given community – around food and housing, for example – and to point the way to effective responses.
Using data to drive decisions allows us to “invest thoughtfully – in the right places, in the right ways – to make real impact for people,” said Trenor Williams, founder and chief executive officer of Socially Determined, a health care analytics firm that measures risk exposure created by a multitude of social factors in counties and neighborhoods across the country, even down to the ZIP code level and below.
This is a particularly important moment to be having these discussions, panelists noted, because of the disproportionate impact COVID-19 is having on communities of color. “We may all be in the same storm, but we’re in different boats going through this pandemic,” said Somava Saha, executive lead of Well-being and Equity in the World and the Well Being In the Nation Network, organizations focused on battling inequities and improving health. “Some of us might be on little dinghies, and some of us might be in ocean liners,” she said, referring to the factors which increase the vulnerabilities of these populations to COVID-19 – including inadequate housing options, unemployment and limited access to health care and chronic disease management.
“We know that there are disparities, particularly racial disparities, and we can see them,” said Heather Cianfrocco, chief executive officer of health services at OptumHealth – though she added that “we’re still not capturing enough race and ethnicity data, particularly in our public health programs.” Optum, a health information technology and services company that is part of UnitedHealth Group, assists millions of Americans with primary and ambulatory care, urgent care clinics and other services.
Williams noted that “social risk” is the largest driver of variation in health outcomes – factors such as housing instability, food insecurity and lack of transportation to get to medical appointments or grocery stores. The promise of using data to understand social risk factors in a community is that it becomes possible to identify who is vulnerable and then intervene with greater precision.
Socially Determined uses measures that get at seven main indicators of community well-being, including the economic climate, access to healthful food and to transportation, housing environment, and the prevalence of crime. The company can create maps visualizing the various risks with great granularity, even below the neighborhood level to a 200- to 400-meter level.
For example, “for understanding food insecurity and the food landscape in a given community, we use 97 individual data elements,” Williams said. Important, for example, are the location and the number of healthy food options, the ratio of healthy to unhealthy options, distance to the nearest grocery store and the affordability of healthy food.
When you know the main issue driving food insecurity, whether it be accessibility or affordability, he said, you can design targeted interventions. “If it’s affordability that is the real driver, then the intervention strategy might be something like produce prescriptions,” he said. “But if it’s accessibility that we’re really trying to solve for, then maybe it’s medically tailored meals – we’ve got to deliver meals out to them.”
Optum and UnitedHealth Group have recognized the power of tapping into such data sources to improve outcomes for their populations, said Cianfrocco. “Because we understand that housing equates to health,” they have invested over $500 million in affordable housing efforts, as well as offering other services to assist with disease management, mental health issues and substance abuse, employment, transportation and food insecurity.
All of the panelists stressed the importance of – in Williams’ words – using data to make decisions hand-in-hand “with” communities rather than doing things “to” them. Cianfrocco noted that a pilot project Optum is participating in in Hawaii has produced several important takeaways. Though population-level data about food and housing security are critical, effective action requires that that information be supplemented by understanding and respecting individual dynamics, because people aren’t always prepared to accept interventions, she said. And it’s vital that community stakeholders be at the table; in this case, local payers, providers and community organizations collectively work together to find solutions, Cianfrocco added.
Statistics can help communities “strategically focus and see patterns,” Saha said, but then they will benefit by considering what their assets are, too, and how they can partner – figuring out “what could we do together that we couldn’t do alone?”
She cited the example of an area in South Texas suffering recently because a lack of broadband access was “compromising access to health, education and jobs together in the context of COVID.” Providing internet access widely became a priority, she said, through a collaboration involving the Federal Reserve and local health systems.
A final point of agreement for the panelists: Data on results of interventions are required as well. A “feedback loop” is key, Cianfrocco said, to know if steps taken are making a difference. Besides pointing to problems and the paths to solutions, Williams said, data provide organizations making big investments in change the means to “measure and refine those interventions along the way.”