Developing an SDoH roadmap requires understanding the Vermont health and data exchange landscape.

The Vermont Agency of Human Services (AHS) needed a comprehensive document describing the benefits and challenges of integrating social determinants of health (SDoH) and health-related social needs (HRSN) data into their state health exchange. AHS planned to use the roadmap to guide the implementation of Vermont’s efforts to create a comprehensive health information exchange (HIE) which includes an individual’s clinical, claims, and SDoH data. The HIE will support development of initiatives and interventions aimed at addressing individuals’ HRSN and reducing health inequities to create integrated whole person care for Vermonters.

NORC developed a multi-year roadmap on how best to collect, analyze, and use SDoH data.

To develop the roadmap, NORC conducted a Landscape Survey and Needs Assessment comprised of a scoping review of peer-reviewed and gray literature, technical documentation, data portals, and other materials on current and potential Unified Health Data Space (UHDS) data inputs, interviews, and an SDoH data source review. NORC also engaged Vermont stakeholders via group interviews and convenings to incorporate perspectives from key constituents and their respective organizations. To support Vermont in implementing the recommendations, NORC created an implementation plan including a training and education plan, and a change management strategy.

NORC’s work will inform Vermont’s approach to identify SDoH impacts on health and improve outcomes.

By leveraging high-quality data sources, adopting best practices, and implementing supportive policies, Vermont can improve health outcomes and create a more equitable health care system. The roadmap will guide Vermont’s UHDS in collecting, standardizing, analyzing, and using SDoH data to enhance care delivery, coordination, and health care operations.

NORC’s landscape assessment offers a comprehensive overview of SDoH data integration across the nation, including methodologies, examples from other states, and Vermont stakeholder feedback. The implementation plan, training and education plan, and change management strategy provide a step-by-step guide with 40 specific recommendations. Additionally, NORC provided a crosswalk of existing SDoH questions used in health care settings and a methodology to keep this inventory updated. Taken together, this roadmap provides a clear path for integrating SDoH data into Vermont’s health system and addressing critical health-related social needs.