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Improving and Promoting Social Determinants of Health at a System Level


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By Ahmad Imran, MD, MBA, system Vice President of Quality and Value Based Care (VBC) at Prime Healthcare Services

Editor’s note: Prime Healthcare Services was awarded a 2021 John M. Eisenberg Patient Safety and Quality Award. Applications for the 2022 award are open through Sept. 14, 2022. Learn more and apply at the Eisenberg Award webpage.


Prime Healthcare Services is honored to be a recipient of the 2021 John M. Eisenberg Patient Safety and Quality Award in the National Level Innovation in Patient Safety and Quality category for its system-level efforts to improve and promote social determinants of health (SDoH).

SDoH, such as low socioeconomic status, race and ethnicity, poor environmental conditions, food insecurity and inadequate access to healthcare services, are known to adversely affect health outcomes, morbidity, life expectancy, mortality and healthcare expenses. Even the best healthcare services improve patients’ clinical outcomes by only approximately 20%, while the remaining 80% is influenced by SDoH that exist outside hospital walls. Initiatives that directly address SDoH factors have the potential to create fundamental change and reduce health disparities and inequities.

Prime Healthcare Services developed a model to address SDoH needs that is focused on supplementing its existing care coordination process with digital innovation, while leveraging a highly skilled multidisciplinary team of physicians and mid-level providers, care coordinators, case managers and social workers, while also strengthening relationships with community partners. Prime extended the scope of its services by increasing its providers’ and care navigators’ presence in the community to assess community needs and foster hospital-community relationships. System-wide initiatives implemented to address SDoH factors include:

  1. Identifying SDoH needs based on an opportunities index

    A SDoH screening tool was created and administered to patients upon hospitalization to identify risk factors and assign a risk stratification score. This helped prioritize patients’ SDoH needs. Post discharge, patients’ SDoH needs were reassessed using a web-based portal. Prime’s team collaborated with community partners to update information on this portal.

  2. Engaging multidisciplinary teams

    Prime’s clinicians, administrators, care navigators, social workers and other team members were actively involved in assessing patients and understanding their individual needs. This multidisciplinary team involved patients and their family members to understand patients’ strengths and ongoing social challenges. This approach allowed the team to tailor the care plan and create an opportunity to provide optimal care based on patients’ beliefs and their unique social and economic barriers.

  3. Building community outreach programs and strong preferred networks of community resource partners

    Prime continued to build effective relationships via ongoing meet-and-greet sessions with community partners. Upon identifying the SDoH needs of its patient population, Prime initiated a community outreach program via two tracks:

    Assistance Track:
    Maintain a community resource directory, identify the right community partners to address patients’ needs and provide pertinent information to community partners to assess patients’ needs.

    Alignment Track:
    Encourage community partners to align with initiatives from the Centers for Medicare and Medicaid Services (CMS) to address social health needs and ensure that services provided to patients improve their health outcomes and lead to their safe transition back to the community.

    Further, Prime integrated all its efforts to provide well-coordinated care that spanned from inpatient care to outpatient care and resulted in safe transition back to the community.

  4. Establishing bidirectional flow of information and real-time patient monitoring

Understanding the need for real-time patient monitoring and timely care updates, Prime collaborated with a third-party vendor to develop the CareSpace platform to connect with community resource partners and track patients’ well-being in real time. This platform has helped Prime to establish a systematic process to identify and address SDoH needs of patients outside its hospitals. After discharge, community partners shared patients’ progress and updates with Prime hospitals. This information was further analyzed to study the program’s effectiveness in achieving better patient outcomes, better experiences and utilization optimization.

Development of an SDoH screening tool, prioritizing high-risk factors, involving multidisciplinary teams and strengthening the post-acute network were pivotal in addressing the importance of SDoH factors in patient outcomes that in-turn resulted in readmission reduction, and lower mortality and complication rates. This also improved cost alignment with CMS’ payment reforms initiative and value-based care.

Prime’s initiatives across different markets addressed the SDoH needs of more than 50,000 patients annually. To learn more about these efforts, read this open access article from The Joint Commission Journal on Quality and Patient Safety.


Dr. Ahmad Imran, MD, MBA, is system Vice President of Quality and Value Based Care (VBC) at Prime Healthcare Services. In his current role, he oversees VBC initiatives, quality improvement, regulatory compliance, infection prevention, and risk management for all 45 Prime hospitals nationwide. He is the executive sponsor for corporate wide initiatives including but not limited to Bundled Payments for Care Improvement Advanced (BPCI-A), Comprehensive Joint Replacement Program (CJR), and Primary Care First (PCF). Under his leadership and direction, Prime Healthcare has been nationally recognized for award-winning quality care and has been named a Top 10 and Top 15 Health System by IBM Watson Health. He plays an instrumental role in spearheading Prime's efforts to promote high value care that led to multiple Patient Safety Excellence Awards from Healthgrades and Leapfrog. His past experiences include leadership roles in Clinical Operations and Quality in acute care hospitals in LA region.