Winner of Innovation Challenge Delivers Unique Population Health Insights for Healthcare and Life Science

June 18, 2019

Earlier this month, Socially Determined won the LifeBridge Health and CareFirst Innovation Challenge. As the winner of the challenge, they have the opportunity to collaborate with LifeBridge Health and CareFirst to run a pilot program of their technology in Baltimore. The judges specifically asked Socially Determined work with key players in Baltimore City and use their technology to bring tangible change to the community.

Founder and CEO, Dr. Trenor Williams, says the most exciting aspect of this project is bringing a payer and a provider together, a novel combination for this industry. The opportunity to combine Socially Determined’s technology with the data and knowledge of these two organizations on a common platform will set the stage for a real opportunity to solve the city’s complex problems. “When we go into new communities our ask is to pull all of these stakeholders together, we know it isn’t just one organization that will be able to make the biggest impact by themselves. If we can instead start to braid and integrate the work that so many vital organizations do and bring them together, we can have an incredible impact.”

Socially Determined is bringing many aspects of public health, healthcare, and medicine together; industries that have historically been heavily segmented. Socially Determined’s analytics platform has been live since early 2018. Dr. Williams started the company on several premises surrounding social risk, healthcare, and the ability to align financial incentive to improve them. One of Socially Determined’s core beliefs is that social risk, whether it is at the personal, family or community level, has a significant impact on health and healthcare.

This fact has become more relevant and experts are beginning to have more thoughtful conversations around this, but no organization has been able to utilize this information to implement change, until now. Socially Determined’s novel analytic platform has the ability to map communities across the nation by their Social Determinants of Health (SDOHs) and assign risk factors at the national, state, community, and individual level. SDOHs like economic wellbeing, food and home insecurity, transportation barriers, health literacy, and crime all have significant impacts on clinical and financial outcomes and prevent individuals from being as healthy and stable as they could be.  

Socially Determined is paving the way to a solution for healthcare’s intricate problems by integrating social and clinical data combined with tangible patient-centric interventions. Their data-driven approach has the ability to identify patients at risk and connect them to social interventions that match the specific needs of socially and clinically complex patients. Recently, Socially Determined partnered with a provider to identify more people who could benefit from their services, including the financial opportunity center, their “Market on the Green” program, and their grocery store that they built in the largest food desert in the city.

Gaining access to such data is not an issue at this day and age, it is knowing how to see its value. “Uncovering the useful information within data sets takes immense focus and domain knowledge, but most importantly you need to know the questions you are trying to answer and what problems you are trying to solve,”  explains Dr. Williams.

Their technology is able to take vast amounts of  data and scale down to a fine granular area, as close as 200 meters in given zip code. Dr. Williams believes the specificity of location matters, “We want to understand what’s going on in a community, how social risk is impacting their lives at a personal level.” There is a belief today, that your zip code plays a more important role in your health than your genetic code, depending on which part of the city you live in, your life expectancy could be vastly different.

Socially Determined’s technology has the ability to run an analysis on hundreds of thousands of people at a time and can narrow down the results to a specific location and number of people with a disease. For example, you could narrow down results to where and how many pregnant women are in Baltimore that have gestational diabetes and hypertension, and if they are at a high risk for food insecurity. Once this information is available, organizations can start to think differently about how they can better support these patients.

Socially Determined is also working with big pharma and life science companies as Dr. Williams explains, “These companies are a large anchor in our healthcare and ecosystem. For example, we are currently partnering with Pfizer, their organization holds the same belief that social determinants affect both medication and vaccine adherence. There is an opportunity for their organization to participate in collaborative work when we go into a community to provide information about social risks and adherence, so we support them in doing so.”  

Socially Determined’s platform can also help address both the selection and retention of patients in clinical trials by helping physicians and hospitals better understand the social risk the participants face, providers can intervene and better support them. Possibly leading to fewer dropouts and shorter clinical trial periods ultimately driving down the cost of research trials.

Socially Determined’s platform has endless implications for how this data and information can be used to impact healthcare on a local and broad scale. Whether it is looking at their risk visualization maps for strategic city planning of where to develop the next grocery store or what resources an entire zip code is lacking and how to connect helpful organizations to those who need them. Socially Determined believes there are significant ways to align financial incentives for payers and providers to dive deeper into the reimbursement systems we have in place to reduce total cost of care and improve outcomes for patients everywhere.