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Breaking Down Barriers for a Healthier Community

Tuesday, March 29, 2022 | Community Outreach
Did you know that up to 80 percent of an individual’s health outcome is impacted by their Social Determinants of Health (SDoH)? SDoH refer to the key areas that include housing, transportation, food insecurity, financial problems, domestic or intimate partner violence, and community or family support. The research in this area and a push to better understand and address it through intervention has been growing nationwide, and has been underway at Bayhealth. Tackling the challenges of SDoH is an important part of Bayhealth’s commitment to population health and living out its mission to strengthen the health of our community, one life at a time.

Evidence shows that when individuals struggle with one or more of these SDoH factors, or experience poverty in general, they are more likely to lack health insurance and have unmet medical needs, including access to primary care and care coordination. The Centers for Disease Control and Prevention’s Healthy People initiative highlights the significance of addressing SDoH to promote good health. Additionally, the National Association of Accountable Care Organizations (NAACOS) recognizes SDoH as a leading priority in improving health inequities.

Efforts to address individuals’ SDoH began at Bayhealth in 2020 after some team members participated in a national learning collaborative rooted in the concept of “doing well by doing good.” During a 6-month process, Bayhealth collaborated with fellow participant Mount Sinai, New York City’s largest academic health system, and several other health systems from across the U.S. and Puerto Rico to create SDoH workflows and methodologies that would best serve their respective patient populations. The Bayhealth group used a screening tool recommended by The Centers for Medicare & Medicaid (CMS) and tools in their electronic health record (HER) to carry out a process for documenting patients’ SDoH needs and referring those patients to community agencies or resources.

At the helm of this important new initiative are Bayhealth’s Clinical Integration team and a SDoH workgroup that includes multidisciplinary clinical and non-clinical team members from across the organization. A Community Outreach Committee was formed around the same time that SDoH efforts took off. Managed by Bayhealth Volunteer Coordinator Carrie Hart, this outreach committee is helping Bayhealth better serve the needs of all our community members and working with the SDoH workgroup since the community integration element is key to the success of these efforts specifically.

The SDoH workgroup began with a pilot program within Bayhealth’s cardiovascular service line. It targeted those in the community experiencing heart failure, which has been identified as a priority health concern among individuals in Sussex County.

“Many of our hospitalized heart failure patients were dealing with other challenges in their lives that made it even harder for them to stay healthy. They were referred to the right resources to get the help that they needed—whether it was food from a local food bank or getting transportation to their clinician appointment,” said Bayhealth Program Manager for Population Health Tasheema Heyliger. “There was a 67% decrease in hospital readmissions for heart failure patients. We knew from there we needed to get all units at Bayhealth involved to implement this on a broader scale to help more patients.”

The pilot program data enabled Bayhealth team members to track data for SDoH patterns and determine next steps to mitigate the effect of SDoH on health outcomes for all patient populations. Heyliger said that education of clinical and non-clinical team members is a key focus for them right now. “We want to build upon our progress and ensure that inpatient and outpatient staff are trained on how to elicit a SDoH history, gather data, and make appropriate referrals.”

Bayhealth Director of Clinical Integration, Evan Polansky, who has been instrumental in moving the SDoH efforts forward, explained that only about 10-15% of total care costs in the United States can be addressed by medical interventions alone. “Many other variables in people’s lives influence an individual’s health and therefore tie into the remaining costs of care. Addressing these factors is a vital step in improving health outcomes as well as avoiding unnecessary emergency department visits and hospital readmissions. More importantly, we are here to take care of our patients, so understanding and working to meet all the needs that are impacting their health is the right thing to do.”

If you are in need of a primary care doctor or specialist, go to or call our referral line at 1-866-BAY-DOCS (229-3627).

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