Social Determinants of Health

Community Spotlight: Sonia Panigrahy, Senior Director, Quality and Technology Initiatives, at CHCANYS


We recently sat down with Sonia Panigrahy, Senior Director, Quality and Technology Initiatives for the Community Health Care Association of New York State (CHCANYS) to talk about health centers’ relationship with data collection and the role social determinants of health play. We also covered some of the challenges and victories she’s seen in her four years overseeing a team of practice facilitators that provide technical assistance for many of the 70 community health centers across New York State. 


How do you define social determinants of health? 

Social determinants of health have a profound impact on any health center and their patients since the vast majority of a patient’s time is spent outside a clinical engagement. These determinants are the non-medical and social factors that impact a patient’s health and well-being. In a public health setting, this includes things like food insecurity, housing stability, education status, and safety at home that influence their ability to prioritize their health, self-manage chronic diseases, and prioritize preventive care.

What are the top determinants you see in New York? 

Food insecurity, housing stability, and transportation, from my perspective, are the top three non-medical factors that impact the lives and well-being of our New York communities. Demographics can change that dynamic too — for example, for our health centers who work with migrant populations, immigration status plays a major role in access and care outcomes. 

Why should health centers be concerned about collecting data around social determinants of health, especially if it doesn’t directly impact reimbursement? 

Community health centers, while mission-driven, are still working largely within a fee-for-service model. Yet as the landscape is moving toward a value-based payment model, health centers are changing their scope to understand how to manage population health outcomes, much of which is heavily influenced by social determinants of health.

For these organizations, collecting data is critical to their success. If they can connect the dots, they’ll understand that addressing social determinants of health in a way that centers data and communication will move them closer to their goals. 

In a fee-for-service model, functions that are critical to mission-driven organizations, like case management, community health coaching, and population health management often aren’t reimbursed by health plans. This leaves health center leaders in a challenging position of finding the resources and staffing that yield long-term value and return on their investment. It’s a challenge to make that transition.

What would you say to health centers who aren’t asking questions around social determinants of health because they don’t feel they’re equipped to take action?

Some health centers simply don’t ask these questions, but it’s not because of a lack of dedication to their mission — in many cases, they simply don’t have the time, don’t know what to do with the answers, or are navigating a role health centers don’t typically hold. 

Take the situation of a woman navigating domestic violence in her home environment. If this information is collected by a clinic staff member on a screening form during a clinic visit, that staff member might not have the skills or awareness of community organizations to take it to the next level. 

While referral to a behavioral health professional could be a good option, in this case, resources in neighborhoods are complex, often changing, and sometimes may not be providing the appropriate services. There are simply too many factors at play for an individual staff member to address on their own. 

This is where partnerships, or “community linkages” become critical — identifying community partners, building relationships, and pulling documentation from both partners’ information systems to validate that services are effective.

Health centers, in order to most effectively address social determinants of health, will benefit from stretching outside clinic walls to establish partnerships. This can be difficult because every organization has its own culture and documentation processes. 

A health center could refer the woman to another organization, but they won’t know if it’s beneficial until the patient comes back and lets them know or until the center follows up on the referral. True community linkages need bi-directional feedback to be effective and go beyond patient self-reporting.

Another case is diabetic and hypertensive patients. While a health center can refer to them to a food pantry, it’s also important that the pantry knows to direct them toward low-sugar or low-sodium options. This dynamic is the foundation of a medical-social partnership.

What’s the process of taking a health center from ground zero to developing scalable data collection processes around social determinants of health?

CHCANYS works with our centers in walking them through a process and equipping them to create community linkages and enable those medical-social partnerships through the use of technology. This has been especially important for centers who are already making an effort but aren’t doing it in a way that scales. 

The process varies for each clinic, but generally walks through the following steps:

1. Establishing Desire

A health center has to realize they want to make collecting social determinants of health data a priority, then, decide what data points they want to collect based on what’s most important for their patient population.

2. Identifying Screening Tools

The right screening tools are critical to seeing success. We provide standardized options, but our centers can choose the options that are most appropriate for their clinic.

Our health centers are equipped to embed an electronic screening form into their analytics platform for social determinants of health from which they can run reports as needed. For example, staff members can pull reports for patients who are identified as food insecure and then use that list to refer them to local food pantries.

3. Embedding Tools into the EMR 

Most CHCANYS centers are on eClinicalWorks, but they work with a variety of systems. Embedded screening tools, along with structured data, allow clinics to view trends like food and housing insecurity at an aggregate level, but also patient-level data to scale intervention efforts. 

4. Identifying a Patient Subset to Pilot

To avoid overwhelming the primary care delivery process, smaller segments of the patient population should be selected to pilot test a set of questions using a screening tool among a smaller volume of patients. Responses should be documented in an embedded EHR to allow for identifying trends that may indicate a need for targeted interventions. 

5. Selecting and Preparing Staff

CHCANYS' team of Certified Practice Transformation Coaches supports health centers by working with them in-person and remotely to provide tailored guidance for each clinic since every clinic has unique nuances in their patient needs, operational capacity, technology adoption, and staffing models. 

We believe the close relationships between CHCANYS and health centers have provided useful insight into what clinics need to effectively implement a robust workflow from start to finish to identify how to collect and act upon the data.

An added benefit is that these processes and community linkages can help identify community needs, which in turn supports the case for requesting additional resources for a health center. Addressing social determinants of health can even help address physician burnout by lightening their load in collecting information to support quality metrics like HEDIS measures.

Next Steps for Your Health Center

The most important takeaway is that clinics across the country have a growing opportunity to support their missions by taking a fresh look at social determinants of health and bringing on the processes and technology that support that new perspective. 

We’re grateful for Sonia sharing her views on social determinants of health data collection and sharing the five steps that will hopefully support your work as a health center leader. 

As a dedicated technology partner to non-profit organizations, CareMessage is aligned with CHCANYS’ efforts to equip health centers and help them best serve their underserved community members. 

We’d like to invite you to learn more about our work with social determinants of health here.

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