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Three Steps to Identify and Address Social Determinants of Health


Jessica Schiller, RN, BSN, MAS, Director of Clinical Programs at Wellframe

Social determinants of health (SDoH) reflect a wide variety of factors, including where people live, their education level, their occupation, and their ability to access support networks. SDoH can significantly impact a person’s wellbeing and can act as a predictor for conditions like heart disease, stroke, and diabetes. 

Given the impact of SDoH on the health care system, it is no surprise that many health plans have implemented programs, solutions, or resources that assist with food delivery, housing, transportation, social services, and other needs. But despite having these resources in place, health plans often face critical obstacles in identifying social barriers, creating workflows for resolving these barriers and establishing a mechanism for ongoing monitoring to ensure interventions have taken place. Outlined below are three key steps that health plans can take to help reduce the impact of SDoH by identifying barriers and directing members to resources that can help them.  

Step One: Uncover When Someone Has a SDoH Barrier

Care teams often struggle to reach, engage, and enroll underserved populations in care management through traditional telephonic outreach, since many members do not have a home phone, may frequently change addresses, and/or often unable to pick up calls during business hours. This is where digital health management platforms and virtual health comes into play. Health plans can capture day-to-day information on members’ needs and behavior that they would not have access to otherwise by capitalizing on alternative forms of communication. For example, they could utilize technology that enables texting or video chat channels, allowing patients to reach care teams on their own terms and at their convenience. This also creates a way for health plans to build long-term relationships with members and cater to their individual needs. 

Step Two: Surface Social Determinant Barriers to Care Teams 

A digital platform can generate unique and valuable data and more frequent touchpoints and can help build a human relationship that uncovers nuanced insights. But an important step to helping patients is leveraging technology to get the information in front of the right people. 

One of the uses for digital platforms is keeping care managers, such as on-staff nurses or counselors, informed of barriers patients have identified and creating relationships that allow them tp get to know patients so that they can help find solutions. For example, if a patient shares that they’re unable to access certain health care services, care teams should have enough background on the patient to direct them to resources that are accessible to them and fit their specific needs. 

Step Three: Triage the Member to the Right Resource or Benefit

Health plans are investing in new partnerships as well as new staff members and resources to address a broader range of member needs. But these resources cannot be effectively utilized if members are not connected to them in the first place. 

As the first point of contact with the member, care managers should be equipped with a platform that enables them to seamlessly triage member needs and connect them to the right services, from specific health plan programs and resources to specialized staff, such as social workers, behavioral health specialists, dieticians, or pharmacists. 

By streamlining these resources, the care manager is able to follow up with each staff member to confirm that the member’s social barriers were addressed. The care manager can also provide ongoing follow up and support to the member to make sure they have the health guidance and resources they need.

Key Takeaways

Though health plans are investing in benefits to address SDoH, most do not have a way to actually connect members to the right resources at the right time. By utilizing digital health platforms and other technologies, health plans can ensure that patients are getting the care they need and are being connected with people who understand their individual requirements and can provide appropriate resources.

While health plans play an important role in this equation, all members of the health care ecosystem, including providers, also need to understand how to identify and address SDoH. Through collaboration, as well as partnerships with community partners, providers and health plans can ensure patients have access to the right resources to address SDoH on their path to better health. 

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