Find The “Digital Dust” For SDOH

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

There are new opportunities in meeting the social support needs of high-needs consumers. Our team has developed frameworks for adding social support components to current services—or developing new social support programs.


The question for executive teams is, what does that look like in practice? A year ago, we had a firsthand look at that from Michael Franczak, Ph.D., Director of Population Health at Copa Health, in his 2021 OPEN MINDS Executive Leadership Retreat session, How To Build An SDoH Foundation Within Your Whole-Person Care Organization. Dr. Franczak said the key is tracking the “digital dust.”

Copa Health is a non-profit founded in 1957 to advocate for those with special needs due to intellectual and developmental disabilities (I/DD). Their service lines have since expanded to include behavioral health, primary care, and five integrated care clinics. Copa Health serves over 11,000 consumers with a serious mental illness (SMI) and 4,000 consumers with a general mental health diagnosis and I/DD through its five integrated care clinics.

Copa Health’s expansion into social supports started with a change in policy from the Arizona Health Care Cost Containment System (AHCCCS), the state agency that administers Arizona’s Medicaid program. In 2019, AHCCCS launched the Whole Person Care Initiative (WPCI) to provide integrated medical/behavioral/social care through maximization of the current Medicaid benefit package. As a result, Copa Health expanded their integrated care approach to include a broader look at social determinants and developed new social support services lines.

How does Copa Health’s approach address the social support needs of consumers? For all consumers, Copa Health does a functional risk analysis, looking into many common determinants such as housing, housing stability, homelessness, food security, loneliness, and transportation. Dr. Franczak discussed their use of housing, literacy, and “no show data” (“a proxy for engagement”) in this process.

“In our functional analysis, we look at the thing driving the behaviors”, Dr. Franczak said. “We can find out when we do this routinely twice a year, or when there is a change in condition. We can gather data on all these factors, in addition to the support network in the community. I believe that the behavior a person has can give us information. Just like Amazon, when you order a book, you will get an advertisement for a similar author or theme, and that’s because they know your pattern of making choices. And when a person makes the choice to go to the emergency department 97 times, they leave what I call digital dust. Digital dust is that they make a decision, and I can see it in the record. Now, why are they deciding that? To turn things into actionable information, I use their decisions to guide their interactions.”

The takeaway in this session on making “whole person’” care a reality was that without rethinking how consumer information—medical, behavioral, and social—is collected, meaningful integrated care is difficult. Even the most committed care coordinators cannot know all the choices made by the consumers in their care. “One of the things in population health is that we need to gather reliable, valid data and turn it into something actionable,” Dr. Franczak explained. “What I’ve seen is that it lands up in a data graveyard, where there is lots of information put in and no one uses it for anything. My job is more than just gathering data and making it digestible for clinicians on the front line. It’s making it into something we use that can impact outcomes.”

The push to “‘whole person” care continues—and with it the opportunity for specialty and primary care provider organizations to develop new care coordination and service models. To be successful, the key is to develop the infrastructure, both in analytics and the ability of clinical teams to use that data.