Hello everyone. Let's deep dive and explore how social determinants of health commonly known as SDOH are significantly impacting healthcare outcomes of member populations, particularly in rural healthcare settings where integration into clinical workflows, presence, unique challenges currently in us. 10.2% of households are facing food insecurity and nearly 580,000 member population is experiencing housing instability. Addressing these SDUH factors through structured healthcare interventions is crucial for health equity. This presentation offers evidence-based strategies for screening, operational integration, and community collaboration to effectively incorporate SDOH into healthcare systems. Let's explore how standard tools and advanced analytics can transform care delivery leading to measurable improvements in patient outcomes and organizational efficiency. Let's look into what healthcare and SDOH. Factors are the important SDOH determinants of health are housing, food, security, safety, transportation, and utilities. Let's deep dive housing. Housing stability, or the lack of stability, quality, and affordability of the members for related to housing directly impacts health outcomes. Where unstable housing is linked to increased emergency department visits and delayed care food security. Access to nutritious food affects chronic disease management with food insecurity is, which is prevalent in 10.2% of US households today. Safety, interpersonal safety concerns can prevent proper healthcare engagement and significant impact. Physical significantly impact physical and mental health. Transportation. The lack of real reliable transportation is disabling access to healthcare services where 3.6 million Americans today are missing medical appointments due to lack of transportation and having those barriers. Utilities, any access to electricity, water communication services directly affect medication storage, telehealth participation, and overall health management. There are evidence-based impacts of SDOH integration. We, it has been seen that once SDOH has been integrated into the clinical workflows and healthcare framework. Almost 86% of gain has been achieved in completion of member screenings, where initially there were, the outreach was decreased. But once the integration of SDH has been successfully completed, the rate of screening for all these members have been achieved up to 86%. It has been proven that the number of percentages of emergency visits by the patients in these rural settings have decreased by 28%. Once the SDOH intervention has been implemented. Let's look into how these screening F framework and how we can standardize this screening framework. There are several steps to it. Effective ING implementation requires careful consideration of patient population characteristics, clinical workflow integration points and staff capacity. Organizations have to monitor screening completion rates and positive screening follow UPS metrics to continuously refine their approach. There are a couple of ways to do it. One implementing Core Five screening tool, which is nothing but adopting standardized questionnaire, addressing food insecurity, housing instability, transportation barriers, utility needs, and interpersonal safety concerns. Next comes determining how, and when the screening has to occur. That is determining the frequency, establishing protocols for initial screening and periodic assessment based on risk stratification with high risk patients. Screened quarterly is important. Next is how do we integrate this into the clinical workflows? Embedding screening within EHR systems at key clinical touch points, including annual wellness visits, transition of care, and chronic disease follow-ups is vital. The last step comes into training the clinical staff, providing comprehensive training on screening, administration, response interpretation, and appropriate intervention. Pathways are needed to identify who is and how much staff training is required. Organizations that have implemented this re, this Restructured Care team model report significant improvements in patient engagement, where previously it was difficult to reach populations. Currently with this implementation, they have shown about 75% participation in recommended interventions. This integrated approach ensures that the clinical and social care coordination is at the maximum. Let's look into, let's compare the traditional clinical team and the enhanced team structure. The traditional clinical team consisted of finish physicians. Nurses, medical assistants, and all of their focus was on medical diagnosis and treatment, where limited capacity was focusing on social, addressing social needs. Whereas the enhanced team structure is an integration of social workers and community health workers who specialize in SDOH assessment interventions and community resource navigations. The enhanced definition of workflows and responsibilities give a clear delineation of roles with structure protocols for SDOI screening interventions, referrals, and follow up processes. One more important aspect is the ongoing performance evaluation, regular assessment of team effectiveness through metrics including intervention, completion rates, and patient outcomes and resource utilization has also proven to be very beneficial. Let's look at some analytics that are related to SDOH risk stratification. Advanced analytics enable healthcare organizations to move beyond reactive approaches to proactive identification of social needs. There are multi-dimensional data sources that providers can prioritize outreach to patients. Let's look at what are they one pro productive modeling machine learning algorithms today provide 89% accuracy in identifying high risk populations. Integrating data by combining clinical claims and community level data sources is an important factor. Geospatial analysis, how do we track consensus, track data, neighborhood level, SDH, risk mapping. That is also a vital factor at the end. Clinical data foundation. The entire documentation that exists in EHR and structural assessment is important for overall analytics and risk stratification done by SDOH framework. Proper EHR integration also has shown to enhance data quality by 45%, which is a significant improvement from the current situation that is is aimed in today's. Where referral accuracy and care coordination shows sign significant improvement. Organizations implementing comprehensive SDOH data standards report better clinical decision making and more effective resource allocation. Let's look into some of the critical factors, structured data capture. How implementation of standard SDH data, hand data elements like law and SNOMED and ICD 10 ensures consistent documentation and interoperability across systems utilizing fire based APIs and HSM standards facilitates secure information sharing between healthcare systems, community-based organizations and public health entities. Outcome tracking, creating dashboards and reporting mechanisms to monitor intervention effectiveness, referral completion, and population level SDH trends over time has been crucial. Deploying automated alerts and intervention pathways triggered by the positive SDUH screenings with tailored research recommendations based on identifying needs as vital. Studies also show that structured community partnerships lead to 70% better outcomes for vulnerable populations compared to isolated interventions. Successful healthcare organizations invest in relationship development with community-based organizations to create sustainable support networks addressing, excuse me, addressing identified social needs. Let's look at some of the variations and factors involving how community partnership framework can be well can be done. Resource mapping is number one, comprehensive intervention inventory of community resources with capacity eligibility criteria and service details is important of how the resource mapping is done. Formal partnership agreements, structured MOUs, defining roles and responsibility on how the data sharing and sharing protocols have to be done. How the agreements have to be done is part of this framework, shared outcome measurement. But today, where everything is, the data is not shared with this joint evaluation frameworks, it helps to assess partnership effectiveness and impact. Let's look into what kind of implementation strategies are IMP are beneficial in a rural setup. Number one being telehealth integration, leveraging virtual care platforms to extend SDOL, screening and intervention capacity across geographic barriers that improves significant store and forward capabilities for the nurses and healthcare workers. The transportation issues that are currently there. SDOH implementation brings solutions to that developing ride share partnerships, volunteer driver programs, and mobile health units to address distance barriers, coordinating appointments, scheduling to minimize travel burden through clustered appointments and regional service hubs. Alternative payment. Payment models like out adopting outcome-based reimbursement structures that recognize SDH intervention value with rural organizations reporting 58 persons increase in successful social interventions through value-based care arrangements. Let's look into what kind of technology infrastructure requirements are needed to implement this SDOH based framework and healthcare system. Number one, being a secure cloud infrastructure, having a HIPAA t hosting environments with role-based access controls and end-to-end encryption so that there is sensitive SDH data is encrypted and is important. For integration, any integration, metalware requires an API management platforms, which facilitate secure data exchanges between EHR systems, community resource directories, and referral management tools. Multi-channel access mobile applications, and responsive web interfaces, enabling SDO, screening and interventions across diverse clinical and community settings. Offline capabilities for rural areas with limited connectivity is crucial. Primacy framework is one more aspect. Comprehensive consent management systems addressing various sharing requirements for SDOH. Data granular permission structures, allowing patients to control information disclosure is vital. Let's look at the implementation roadmap and key success factors. On a very high level, the program design today takes about one to three months. This involves assessing organizational readiness, establishing governance structure, and defining specific SDH focus areas based on community needs and organizational capacities. The next set of months from month four to month six, deals with infrastructure development. We're implementing in technical infrastructure, including EHR, customization, analytics platform, and developing standard workflows and staff training programs. That is where this month four to six consists of. Next comes the initial implementations. From month seven to nine, launching the pilot program with targeted pa, targeted patient population, establishing baseline metrics, formalizing community partnerships, and is involved in this phase. Next comes expansion and optimization in the following months scale to full patient population, refining the processes based on initial outcomes and implementing advanced analytics that we just went through for continuous improvement and also developing sustainable funding mechanisms. All of this is a overview of how an implementation roadmap and what are the key success factors of implementing SDH framework looks like. Successful SDH implementation hinges on executive leadership commitment, dedicated resources, and a culture of continuous crosses. Quality improvement organizations should establish clear metrics for success, including clinical outcomes by following the structured approach. I hope I was able to provide you a high level at yet a detailed overview of SDOH and how the care delivery models are ultimately improving health equity and patient outcomes at the same time, optimizing resource utilizations. Thank you.