Area Level or Individual Screening – What SDOH Data Is More Useful?

The Montana Index for Healthy Communities (MT IHC) is a health and social needs index that uses area-level data to shed light on the many factors that contribute to health and well-being.  

Meanwhile, your hospital is probably also collecting SDOH screening data for many or all patients.  

What is the difference between these two data sources? Which one is better? 

Area level health and social needs data and individual SDOH screening data are complementary. They give us different perspectives at different points in time. Taken together, they can lead to a well-rounded understanding of what needs exist in your community, where those needs are most acute, and how you can take steps to support patients.  

MT IHC – Area Level Data. The MT IHC uses data sources like the American Community Survey to geographically show levels of need. Every zip code in Montana has a set of scores for each domain, from internet connectivity to food access to health care provider supply. The index makes it easy to understand, at a glance, which domains have relatively higher levels of need AND which zip codes have relatively higher levels of need. It can help us strategically design programs that will have the greatest impact. 

The MT IHC data is a snapshot in time. Many of the data sets rely on surveys that are conducting annually and include only a sample of the population. They help us see patterns but not the details of individual needs and changing circumstances.  

SDOH Screening – Individual Data. Most hospitals are now screening patients for at least five health-related social needs during every inpatient state: housing instability, food insecurity, difficulty paying utilities, difficulty with transportation, and interpersonal violence.  

This information is timely. It reflects that patient’s current situation and can help the care team connect them to resources or adjust their care plan as needed to account for their circumstances. This information helps the care team provide support in the moment.  

Over time, hospitals can also analyze their screening data in aggregate to identify patterns. They may observe higher levels of need related to housing instability versus food insecurity, for example.  Or they may see need increases at a certain time of year—such as food insecurity increasing when school is out for the summer. Monitoring these data can help hospitals recognize an emerging pattern and quickly devote new resources.  

SDOH screening data is also only a sample of the population. It only tells us about the needs of patients who seek care. Many individuals who are not hospitalized in any given year will also have needs related to SDOH. Those are not captured through the individual screening approach but are nonetheless important to understand and proactively address.  

What’s Still Missing? Area level data and SDOH screening data, especially when analyzed in aggregate, provide us helpful insight on how we can make an impact to improve health and wellbeing. These data sources identify needs neatly organized into buckets like “food insecurity” or “employment” so we have a broad sense of where to start. 

What these data sources don’t tell us, however, are the complex, nuanced, and shifting circumstances that lead to those needs. Are people having trouble getting food because they can’t afford it? Or because they don’t know how about available benefits? Or because there aren’t any grocery stores for miles?   

Regardless of which data source you start with—area level or individual screening—the crucial next step is to partner with patients, family caregivers, community members, and clinicians to have the conversations that illuminate the true nature of these needs. Only then can we work together to design solutions that will solve these challenges.   

How to Take Action. Bring your data—whether it’s the IHC, SDOH screening data, or both, to a community meeting. Open up a conversation about what these data show. Listen. Are these data consistent with people’s lived experience? What do they not show? How else can we partner to better understand the need and start to identify solutions? 

Bringing data is a first step to start a conversation about how we can align together. To learn more about your hospital’s data and ideas for how to use it, reach out to Chloe Williams (chloe.williams@mtha.org)