Better data collection and sharing continues to be central need for addressing SDOH, according to Oregon experts


Eli Kirshbaum


According to RJ Briscione, Principal at the Focus Group, addressing the social determinants of health (SDOH) requires several critical elements: having reliable and current data on folks’ social needs; being on the ground and talking to people face-to-face; and the ability to adjust and make changes.

Briscione guided a panel on how addressing these social needs affects health equity at last month’s 2022 Oregon State of Reform Health Policy Conference. Joining him on the panel were Jess Soltesz, Director for Social Health at Kaiser Permanente Northwest, and Richard Bruno, MD, Senior Medical Director of Clinical Care at Central City Concern, an organization serving homeless individuals in Portland.


Stay one step ahead. Join our email list for the latest news.



The panel conversation had one common theme throughout: data. Advocates across the healthcare sector have long-identified stronger, more coordinated health data collection as paramount to effectively managing SDOH. The panelists doubled down on this.

“How do we collect that data, and how do we make sure we’re reaching the people who really need this, and not just the people we happen to see coming into our clinics on a day-to-day basis?” Soltesz said.

Soltesz noted there are “hidden populations” that current SDOH outreach strategies aren’t reaching, leaving the sector with incomplete data on their social needs. Since folks with SDOH challenges tend to access the healthcare system at lower rates, she said, it’s critical for the healthcare system to conduct proactive, intentional outreach to individuals.

“Unless we’re specifically targeting these populations, we won’t be getting a good sense for what needs are really out there,” she said.

A big part of this is incorporating more community-centered intervention methods, like non-English data collection options and community health workers. She said community health workers need to be involved for longer durations to get to the root of individuals’ social needs.

“In our world, [SDOH are] not going to show up until [patients] show up with some kind of high need in our medical system,” Briscione said. “That’s the only way we have to measure things, unfortunately.”

Soltesz emphasized that the healthcare system doesn’t need to create a new structure for collecting social data, but rather needs to partner with the community-based organizations (CBOs) who are already doing this work and leverage the data they receive about beneficiaries to implement SDOH interventions.

“We can’t just ask to ask, we have to ask for a reason,” Soltesz said of SDOH data collection.

Discussing ways in which COVID affected data collection efforts, Briscione and Soltesz highlighted the digital divide as a prominent obstacle. When organizations rely on electronic outreach methods to identify social needs, only those who have the ability to access the necessary technology or with adequate technological literacy can engage. These are often “rich white people,” Briscione pointed out.

For instance, when Briscione was facilitating COVID vaccine distribution during his time working for Aetna, his team selected vaccine retailers that were near the highest number of Black and brown residents in order to target these underserved populations and ensure they had vaccine access.

However, he discovered that the only people who were signing up for appointments were those who had the technology to be able to reserve vaccine appointments online—not the intended underserved populations.

To ameliorate this, Briscione and his team instead distributed vaccines through trusted CBOs that served these communities, like Black churches. His team also purchased vehicles to conduct mobile vaccine distribution, rather than relying on the online sign-up process.

Soltesz added that it’s important to go into communities and learn directly from them how best to conduct projects like vaccine distribution, rather than presenting a pre-established plan to communities without having consulted its members

The panel also emphasized that the collection of the data is only one piece of the puzzle; the data also needs to be synthesized and put to use in a meaningful way. Bruno pointed out that there are many ways to accumulate data on SDOH—community health needs assessments, providers asking patients directly, payors asking beneficiaries—but not many effective ways of sharing it and using it to bring about change.

This, he said, presents an opportunity for collaboration among the different organizations collecting the data. He urged stakeholders to keep up-to-date with the continually emerging SDOH data from the pandemic and be thinking of ways to use this data to create collaborative solutions.

Panelists also cited some recent examples of successful SDOH-focused initiatives in Oregon.

Bruno discussed how housing has been key during COVID, and how providing housing support can help protect Oregonians from the risks of overcrowding during public health emergencies like COVID. He listed the City of Portland’s Safe Rest Villages initiative as a successful way the government addressed the lack of housing for the thousands of unhoused individuals in Portland following COVID.

Through this project, the city implemented a “pod system” in which it sectioned off areas, or “pods,” to unhoused individuals that contained essentials like heating and lodging. This allowed these individuals to maintain social distancing practices while maintaining access to essentials.

Briscione and Soltesz discussed Health Share Oregon’s successful effort to use data to reach out to members who might be at risk of heat or climate-related health impacts and offer them Medicaid-covered air conditioning units. Health Share Oregon reached out to members who had a history of respiratory illness, etc., and ended up distributing around 300 air conditioning units to Medicaid beneficiaries who needed them during this summer’s heat wave.

Briscione also discussed Aetna’s partnership with Feeding South Florida, which created food pantries at schools for food-insecure families to receive groceries. They also offered a Spanish-language survey of social needs for beneficiaries who engaged with the program.

Once his team identified that transportation was an outstanding issue for these families (many families had limited access to transportation to pick up the food and/or bring it home), they implemented mobile “farmacies” through which vehicles brought food to a network of local clinics that were closer to the families who needed them.

Briscione said this project was found to have significantly reduced the targeted population’s A1C levels.

“I think it gets to the model of: start with something, find a good partner, you’re going to have to adapt and know what you want to measure, and keep going,” he said.