Risk scores are often the basis of care management programs, but they often rely mainly on clinical factors and offer limited actionability. By creating risk scores that take into account addressing social determinants of health and behavioral determinants of health, we can improve risk assessments and highlight intervention opportunities.

Most of wellness happens outside the hospital

Recent research suggests that 70% of health outcomes are attributed to health-related behaviors, socioeconomic factors, and environmental factors, broadly referred to as social determinants of health. One study found that Social Determinants of Health contributed to more than 50% of hospital readmissions.

Moreover, Pieces’ own analysis of patient health outcomes demonstrates that the presence of SDoH negatively impacts hospital outcomes, such as length of stay and readmission rates. By addressing patients’ Social Determinants of Health, Pieces SDoH software aids the hospitals in combating the high costs and other issues associated with hospital over-utilization and excess lengths of stay.

Technology identifies vulnerabilities

The Pieces SDoH Module helps health systems identify, prioritize, and address a patient’s social vulnerabilities. Using AI, machine learning and natural language processing of electronic medical records, the SDoH screening tool module reads physician, case manager, and social worker notes to identify social determinants of health (SDoH) that might otherwise be missed.

How the SDoH module helps

The SDoH module screening tool combines the SDoH with clinical factors, as well as environmental factors, such as neighborhood and living conditions, to provide an overall portrait of vulnerability and risk.
Quickly see and prioritize the most socially-vulnerable patients for better patient outcomes and to focus resources where they are needed most.
Identify key risk drivers, including patient-specific social and behavioral determinants of health, arming care managers with rich insights during outreach.
Inform care resourcing and enable better ROI measurement across initiatives by tracking and monitoring population risk over time.
Efficient Workflows
Reduce the manual screening burden on hospital staff.

ROI Benefits of SDoH Software

Save Time and Be More Efficient
Pieces NLP identifies indicators of social determinants in clinical notes, saving providers time spent in completing manual screenings.
Reducing Readmissions and LOS
Pieces calculates the effect of SDoH on readmissions and excess length of stay. We help you target more vulnerable patients for intervention.
Identify Risk with SVI
The SDoH identified are combined with comorbidities to create a risk score indicative of the effect of patients’ social issues on costly hospital outcomes.

Amy Salerno
MD MHS UVA Health Director of Community Health and Wellbeing
“As a doctor, I write the social context of my patients in my history and physical documentation; and it’s in my notes, and Pieces Predict can pull out that information; and allows us to track SDOH data, and allows us to interact faster with those patients.”

Ready to Learn More?

Our SDoH software modular solution can be tailored to your needs. We’d love to schedule a demo to more fully walk you through how Pieces can help you achieve better outcomes for your patients and your bottom line.