Social determinants of health (SDOH) are the nonmedical factors that contribute to the health of an individual – where you are born, where you work, your income, your age, your race, your religion, etc. Essentially all of the components that make you, you, and societal realities are SDOH. And by nature, humans are social creatures. We constantly seek out companionship to the point that we become emotionally connected to inanimate objects that we can name and attribute feelings to like our house plants or robots like our Roombas or the Mars rovers. Furthermore, just as the phrase ‘birds of a feather’ states, we tend to find that companionship and settle down with people who are similar to us. This means there is a pretty good overlap of SDOH with population health.
So today we are diving into this topic to see just how social determinants of health impact population health outcomes and what initiatives are being implemented to address these factors and reduce health disparities within communities. The following are quotes from our brilliant Healthcare IT Today Community on this topic.
Karen Iapoce, Vice President, Government Programs at ZeOmega
Social determinants of health, such as socioeconomic status, education, and access to healthcare, have a profound effect on population health outcomes and contribute to health disparities. Addressing these factors involves multifaceted initiatives, including community health programs targeting underserved populations, policies aimed at enhancing access to education and affordable housing, and integrated care models providing comprehensive support services. Health plans are increasingly playing a critical role in these efforts by designing benefits and programs that address social needs, such as transportation assistance and food security. Additionally, plans are leveraging generative AI to analyze large datasets, identify at-risk populations, and personalize interventions, helping to predict and address gaps in care. This combination of targeted programs and advanced technology is crucial for ensuring a more equitable distribution of health resources and opportunities.
Saranya Loehrer, MD, Chief Health Equity Officer at Teladoc Health
We know that much of what keeps us healthy and well happens outside the four walls of an exam room, virtual or otherwise. Social drivers of health (SDoH), like stable housing, reliable transportation, affordable medications, and access to nutritious food can play an outsized role in improving the health of people and populations. As SDoH becomes a greater focus for payers, regulators, and accreditors, healthcare delivery organizations are increasingly developing and operationalizing SDOH strategies. However, the medicalization of SDoH is not without peril and requires a thoughtful approach that supports patients, care team members, and community-based organizations.
One of the most common pitfalls of current SDoH strategies is focusing solely on screening patients for health-related social needs (HRSNs) without providing follow-up support for any HRSNs identified. This can be a source of moral injury for clinicians and harm to patients. Models that screen patients for HRSNs and refer to community resources are also frequently challenged by chronically underfunded and under-resourced community-based organizations.
The Anchor Institution model is a promising approach to community wealth building that has been adopted by several healthcare organizations. Anchor Institutions are those that typically exist in communities for decades, like hospitals and universities. The longevity of these types of organizations provides them with a unique opportunity to advance community well-being through their roles as employers, purchasers, and investors. Approaches like those deployed by the National Healthcare Anchor Network create more community-centered solutions and pathways for sustainable economic development that stand to benefit the health system, those seeking care within it, and the community that surrounds it.
Hamad Husainy, DO, FACEP, Chief Medical Officer at PointClickCare
Integration of social determinants of health (SDoH) data into existing workflows is critical for improving care outcomes at scale.
By enhancing care teams’ understanding of patient populations, this data can help today’s providers identify the most effective treatments and interventions. For example, with consideration to high-needs and historically underserved populations, this data equips providers to deliver high-quality, efficient, and equitable care regardless of geographic location or other social determinants.
Advanced technology, such as AI and machine learning, also play a pivotal role in synthesizing and streamlining patient data to gain deeper insights that will ultimately inform care decisions. This innovation can greatly help with not only addressing the challenges of managing population shifts but also enhancing the overall quality of care. Better identification of at-risk populations enables providers to tailor interventions that meet individual patient needs, leading to more personalized, proactive, and preventative care. Leveraging SDoH data and advanced technology also allows care teams to better recommend how to further support patients, including through telehealth. According to the CDC, telehealth utilization remains above pre-pandemic levels – this is because it is a key solution in enabling access to care for populations regardless of SDoH. It is important that data, advanced technology, and telehealth continue to work in tandem to transform health delivery and access – ensuring patients receive necessary treatment while driving down hospital readmissions and overutilization.
Jennifer Goldsmith, President at Tendo
Social Determinants of Health (SDOH) play a critical role in shaping population health outcomes. Factors like access to healthcare, food disparity, quality of living conditions, education, economic stability, and social conditions can create significant barriers that lead to poor health outcomes, particularly in underserved or marginalized communities. Emerging technologies are playing a crucial role in supporting interventions that address SDOH. By relying on advanced data analytics platforms and digital tools, organizations can now gather and analyze data related to SDOH, such as income, housing, education, food security, and more. Integrating these SDOH data with Electronic Health Records, and public health databases creates a comprehensive picture of a patient’s or population’s health, making it easier for healthcare organizations to better understand and mitigate the effects of SDOH, ensuring that resources are directed toward those most in need and reducing health disparities within communities.
Danielle Carter, Vice President, Community Health Transformation at Intrepid Ascent
Today the impacts of social determinants of health (SDOH) on population health outcomes are well studied, but it is important to remember that behind the data there is a life adversely impacted by the environment people are in, where they were born, and the resources they have access to. I have seen the impact of food deserts on children and how lack of access to fresh fruits and vegetables changes their mentality on nutrition, as well as their susceptibility to preventative conditions, such as type 2 diabetes. I have seen our broken healthcare infrastructure affect access to timely and quality medical care, and how poverty and generational trauma increase the likelihood that individuals in a community struggle with substance abuse issues.
The healthcare sector is taking note, and initiatives are being implemented across the country to begin addressing SDOH (often starting with elements called “health-related social needs”, or social needs that have a direct link to health outcomes). Increasingly states apply and are approved for Medicaid 1115 waivers to support enhanced care delivery for some of their most vulnerable populations – moving especially fast in California and New York.
Society is recognizing (and beginning to expect) that in order to thrive, more than just our physical health has to be taken into account. This realization is pushing healthcare to look beyond the clinic walls and into the environments we live in. Some healthcare providers, such as federally qualified health centers, have been addressing SDOH for years, but in the last five years or so we have seen an enormous uptick in larger health systems, as well as state and federal policy, addressing these issues. There has recently been a wave of movement to marry state and federal policy with grass-roots programs in this space. This alignment is a critical step in addressing social determinants of health across the nation.
Weston Blakeslee, PhD, Vice President, Clinical Data Strategies at DrFirst
Low income and low health literacy are major contributors to health inequities, with medication costs being a key factor in non-adherence. When patients can’t afford prescriptions, their symptoms worsen, leading to more severe health issues. Medication fill rates, for example, drop significantly when monthly costs exceed $50. For patients with chronic conditions like COPD, health literacy adds another barrier if they need help to distinguish between their rescue and maintenance inhaler and might otherwise fill or use them incorrectly.
Tools like Real-Time Prescription Benefit (RTPB) let providers check medication affordability during visits. Text messaging helps remind patients to pick up their prescriptions and understand how and why it’s important to stay on track with medication. Population health platforms support outreach, allowing staff to contact patients when personal interaction is needed. This combination of technology and human touch has proven most effective for improving medication management and outcomes, especially in value-based care settings.
Ryan Bengtson, CEO at Panda Health
Social factors have been shown to have as much influence on health status and life expectancy as clinical and genetic factors. Patients lacking economic stability, healthcare access, or education have a more difficult time achieving and maintaining the health outcomes they need and desire. To mitigate the risk of SDoH factors that often lead to higher rates of chronic disease and increased utilization of health services, data-driven initiatives must be implemented to identify those at-risk populations and tailor interventions to meet their unique needs. Health systems across the country are investing in programs to address SDoH challenges, including providing free and subsidized groceries to food-insecure families, offering non-emergency medical transportation (NEMT) solutions that help close the gap for those who may not have reliable access to transportation to life-sustaining care, and in some cases even building housing for the homeless.
Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company
One of the main goals of population health is to reduce health inequities among different population groups. One area where there can be significant discrepancies between population groups is the ability to afford care. With recent studies showing that 63% of workers are unable to pay a $500 emergency expense, healthcare providers need to consider how a patient’s financial responsibility impacts their willingness and ability to seek the care they need. Some ways that providers are successfully supporting patients in this area are by offering flexible payment plans and by providing up-front estimates so that patients understand care costs and can budget accordingly.
Samantha Bockoven Tamminga, Health Clinics Coordinator at The Vineyard Free Health Clinics
Social determinants of health have a massive impact on a person’s overall health. Such determinants can include everything from a person’s access to food, hygiene items, and education to their medical literacy, living conditions, housing, insurance coverage, and transportation options. All of these factors and more play a significant role in a person’s health care. At our free health clinic, each patient completes a social needs screening survey on arrival to the clinic. This allows us to meet the patient’s needs in real-time, whether it is giving them hygiene items, referring them to our food pantry, providing them with free medication, or connecting them with a case worker.
Our social needs screening survey is an important step in our process because it allows us to see the broader picture and provide a more comprehensive care plan. For example, if a patient comes in with a disease, you could treat that disease, but that does not mean that the patient can afford the medication, has a home to go back to, or that they have healthy food options to help their body heal. Our surveys give us the health data we need to better serve the patients who are most in need of health care. Overall, there has been a bigger push across various patient populations to provide whole-person care so that healthcare providers are not just treating medical needs, but also considering how social and environmental factors influence the well-being of their patients as well.
Amanda Gibson, BSN, RN, Mid-Level Account Executive, Government Division at Relias
As a healthcare software professional, nurse, and proud member of the Cherokee Nation, I’ve seen firsthand the impact of health disparities on population and public health. Trauma and oversights have led to lasting generational disadvantages. For example, people from my own Native American community have higher rates of maternal mortality and morbidity than non-Hispanic white people. These adverse outcomes can be prevented with better access to care, education, and bias reduction initiatives. By standardizing high-quality care through comprehensive clinical training and providing innovations through technology and telehealth, we can reach more communities, regardless of location or population density. These efforts can transform rural communities — delivering services where none existed and solving some of our biggest health challenges.
Maria Perrin, Chief Growth Officer at Public Partnerships, LLC
It’s widely recognized that social determinants of health (SDoH) have a significant impact on health outcomes including mortality rates. According to a report from the U.S. Department of Health, social determinants impact as much as 50% of the variation in health outcomes. As of August 2024, 21 states have approved Section 1115 Medicaid waivers to fund SDOH demonstration projects with another 15 states pending waiver approval. These waivers authorize housing and nutrition services for high-need populations. Examples of support include temporary rent and utilities, medically necessary home modifications, and rent deposits for individuals transitioning from institutional care. These programs typically support people at high risk for homelessness, and those with high-risk pregnancies and other high-risk behavioral and medical health conditions. The programs also address youths and young adults at high risk for long-term poverty.
Amy Brown, Founder and CEO at Authenticx
Experts tell us that SDoH are a significant factor in population health. If we aren’t acknowledging and measuring the prevalence and impact of SDoH factors in populations, then we are missing a huge piece of the puzzle. We analyzed nearly 24,000 interactions for one health system to identify instances where an SDoH was mentioned, and factors were discussed in 7% of processed calls.
One initiative healthcare organizations can take is leveraging their unstructured data— or the recorded conversations with patients and consumers—to listen for both the multitude and evidence of SDoH indicators.
While technology isn’t a silver bullet for health outcomes, it is a valuable tool to help address these disparities and SDoH by providing insights that are often overlooked in healthcare, giving companies steps toward solutions and communities the necessary care they seek. Healthcare organizations can listen in real-time and can respond in a timely and more effective way to patients who are facing SDoH factors in their lives.
David Werry, Co-Founder, President, and COO at Well
Social determinants of health are a fancy way of saying that where we live, work, and play has a huge impact on our health. Organizations are really starting to get this, and they’re looking at the bigger picture. They’re not just asking about your symptoms anymore; they’re asking about your housing situation, your access to healthy food, and even your stress levels at work. It’s all connected. And they’re not just collecting this info – they’re actually doing something with it. They’re partnering with community organizations, pushing for better policies, and trying to create a sort of one-stop-shop for all your health needs, finally recognizing that humans are whole people, not just a collection of medical conditions.
Mary Sirois, Managing Director, Performance Improvement Advisory Practice at Nordic
Social determinants of health are a challenge to healthcare organizations because it is impossible to solve all health issues within a population, and lifestyle also factors into health outcomes. From living situations and access to healthy food to a person’s proximity to high-pollution areas as well as individual choices and decisions, there are a variety of factors that impact a person’s health.
For example, I worked with an organization that had a large Korean population having issues with early-stage breast cancer detection. The population was detecting breast cancer too late and experiencing high mortality rates or less than optimal outcomes as a result. To help educate the community, the healthcare organization partnered with the clergy at the local church to help increase their trust in doctors and care teams. Having the backing of a trusted clergy member enabled the organization to provide a mammography truck for community members to get screened, resulting in earlier stage identification and treatment and better outcomes.
By understanding SDOH, healthcare organizations can develop community-focused solutions. Data analytics has allowed us to make and identify these connections and build social networks. Through technology, patients can better connect to the services that they need, whether that is an air conditioner in their home, food delivery from Meals on Wheels, coaching, or counseling.
What great insights! Huge thank you to Karen Iapoce, Vice President, Government Programs at ZeOmega, Saranya Loehrer, MD, Chief Health Equity Officer at Teladoc Health, Hamad Husainy, DO, FACEP, Chief Medical Officer at PointClickCare, Jennifer Goldsmith, President at Tendo, Danielle Carter, Vice President, Community Health Transformation at Intrepid Ascent, Weston Blakeslee, PhD, Vice President, Clinical Data Strategies at DrFirst, Ryan Bengtson, CEO at Panda Health, Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company, Samantha Bockoven Tamminga, Health Clinics Coordinator at The Vineyard Free Health Clinics, Amanda Gibson, BSN, RN, Mid-Level Account Executive, Government Division at Relias, Maria Perrin, Chief Growth Officer at Public Partnerships, LLC, Amy Brown, Founder and CEO at Authenticx, David Werry, Co-Founder, President, and COO at Well, and Mary Sirois, Managing Director, Performance Improvement Advisory Practice at Nordic for taking the time out of your day to submit a quote! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.
How do you think social determinants of health impact population health outcomes, and what initiatives are being implemented to address these factors and reduce health disparities within communities? Let us know either in the comments down below or over on social media! We’d love to hear from all of you!
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