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Social Determinants Strategy�for Value Based Care:�Mount Sinai Health System

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Rob W. Fields, MD MHA

SVP CMO Population Health

Mount Sinai Health System

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Pre-Intervention: Assessment and Predictive Analytics

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  • Standardization

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  • Patient entered screenings

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  • SDH Epic Healthy Planet Dashboards

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  • Commercial Data + Claims +Machine Learning

  • Predict SDH Needs at the Person Level

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  • Customize Assessments

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  • Predict Risk of Unplanned Admission

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Assessment

Predictive Analytics

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Tracking Interventions

  • Relies on Sound Operations
  • Discrete Data Collection at Each Step
  • Approximate ROI impact

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Assessment

Referral

CBO Engagement

Gap Closure

Measuring Effectiveness

With repeated cycles of intervention and data collection, we start to not only build an effective CBO network, but to also measure relative impact on outcomes and reduced cost. We are investing in data driven community-based programming based on attribution and need.