As of late, the health care sector has put an increased focus on addressing the social needs of patients.

Extensive research shows that nonmedical drivers of health, like transportation, housing and access to healthy foods, have a direct impact on one’s health and well-being.[1]

Recognizing and addressing how drivers of health impact a patient’s health is critical for providing personalized, whole-person care. Yet the lack of data sharing across the health care community has made this work challenging.[2]

Why Drivers of Health Matters

According to the National Academy of Science, medical care, including doctor and hospital visits, accounts for only 10 to 20 percent of an individual’s health outcome, while 80 to 90 percent of an individual’s health can be attributed to social, economic and environmental factors, often called social determinants (or drivers) of health (SDOH).[3]

“A person’s health extends far beyond the care they receive in their caregiver’s  office,” said Dr. John Lumpkin, vice president of drivers of health strategy at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). “The social and environmental conditions in which a person is born, live and work are critical to their well-being and long-term health outcomes.”

Improving health outcomes, reducing health care costs and eliminating health disparities all require addressing a person’s health-related needs both inside and outside of care facilities.

The Focus on Data

As part of its commitment to improve the health and well-being of all North Carolinians, Blue Cross NC is taking a data-driven approach to addressing drivers of health.

The insurer recently joined the Gravity Project, a national collaborative of payers, providers and other stakeholders in the health care industry working to improve how SDOH data is captured and shared across health systems.

“North Carolina’s health system is ranked 36 out of 50 states,”[4] said Dr. Lumpkin. “We must take a whole-person approach to improve health on a larger scale. We’re proud to join the Gravity Project and be part of a collaborative network that’s improving our data so we can do a better job addressing the needs of our members and communities.”

The Gravity Project aims to develop consensus-based standards for the use and exchange of SDOH data within the health care sector and between health care and other sectors. These standards will help stakeholders better identify and address the social needs of people.

“Now that we know how critical factors like food security and transportation are to individual health, how can we make sure patients are connected to the right information and resources to meet those needs,” said Evelyn Gallego, program manager for the Gravity Project. “That’s where the Gravity Project comes in.”

The project is working to advance how SDOH-related assessment, diagnosis and intervention information is collected and shared securely within the health care industry and between the health sector and the social services sector. A more standardized approach would allow providers to track and manage an individual’s social risk factors and social needs, and it will facilitate collaborative, strategic interventions with other health care stakeholders and nonprofit organizations to improve person health. This collaboration would help connect individuals to social services and community-based resources and programs. 

“We know unmet social needs negatively impact health outcomes,” said Gallego. “COVID-19 has no doubt exposed and exacerbated the increasing health and social inequities as a result of unmet social needs. We are at a pivotal point in creating a universal language that supports the use and electronic sharing of this data so that our most vulnerable populations can receive the right care and services they need at the right time and the right place.”

The Gravity Project was launched in May 2019 by the Social Interventions Research and Evaluation Network (SIREN) in partnership with EMI Advisors LLC. The project has convened more than 2,000 experts from across the nation to collaboratively develop recommendations that will improve how the industry captures and exchanges electronic information related to clinical activities that support SDOH domains such as food insecurity, housing instability and quality, transportation access, social isolation, financial strain and demographic status.