Integrating social and behavioral determinants of health into patient care and population health at Veterans Health Administration: a conceptual framework and an assessment of available individual and population level data sources and evidence-based measurements

Elham Hatef; Zachary Predmore; Elyse C Lasser; Hadi Kharrazi; Karin Nelson; Idamay Curtis; Stephan Fihn; Jonathan P Weiner

doi:10.3934/publichealth.2019.3.209

Integrating social and behavioral determinants of health into patient care and population health at Veterans Health Administration: a conceptual framework and an assessment of available individual and population level data sources and evidence-based measurements

AIMS Public Health. 2019 Jul 3;6(3):209-224. doi: 10.3934/publichealth.2019.3.209. eCollection 2019.

Authors

Elham Hatef¹, Zachary Predmore¹, Elyse C Lasser¹, Hadi Kharrazi¹, Karin Nelson^{2

3}, Idamay Curtis², Stephan Fihn^{2

3}, Jonathan P Weiner¹

Affiliations

¹ Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
² Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
³ Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.

Abstract

The premise of this project was that social and behavioral determinants of health (SBDH) affect the use of healthcare services and outcomes for patients in an integrated healthcare system such as the Veterans Health Administration (VHA), and thus individual patient level socio-behavioral factors in addition to the neighborhood characteristics and geographically linked factors could add information beyond medical factors mostly considered in clinical decision making, patient care, and population health. To help VHA better address SBDH risk factors for the veterans it cares for within its primary care clinics, we proposed a conceptual and analytic framework, a set of evidence-based measures, and their data source. The framework and recommended SBDH metrics can provide a road map for other primary care-centric healthcare organizations wishing to use health analytic tools to better understand how SBDH affect health outcomes.

Keywords: patient care; patient-centered medical home; population health; social and behavioral determinants of health; veterans health administration.