Incorporating Social Determinants of Health into Care

As we move towards value-based care and risk-based healthcare delivery and payment models, it becomes critical to understand how the social determinants of health (SDOH) play an essential role in population health. According to the World Health Organization (WHO), SDOH are defined as the conditions in which people are born, grow, live, work and age. The CDC has also defined the top five SDOH factors.

Five social determinants of health of a population

1. Biology and genetics. Examples: sex and age
2. Individual behavior. Examples: alcohol use, injection drug use (needles), unprotected sex, and smoking
3. Social environment. Examples: discrimination, income, and gender
4. Physical environment. Examples: where a person lives and crowding conditions
5. Health services. Examples: Access to quality health care and having or not having health insurance

The social determinants of health are responsible for most health inequities. There is a tremendous amount of money and time spent on preventable illness due to changeable behaviors. The AMA Journal of Ethics notes that these conditions have a profound effect on health care finance, with 75 percent of medical costs in the U.S. spent on care of individuals with chronic illnesses and 25 cents of every health care dollar spent on the treatment of diseases or disabilities that result from potentially changeable behavior.

Understanding how to incorporate SDOH into care starts with the right workflows. The first opportunity to gather SDOH data is during the intake process. Our intake process typically focuses on the medical information, but it also creates an opportunity to obtain invaluable SDOH information. Asking the right questions at the right time also helps get a person more engaged in their care. It makes a person feel like you are spending the time to get to know them and not just their acute care condition. When SDOH data is collected upfront, it eliminates the need for follow-up surveys. If this data is captured electronically, it can be integrated with clinical data to get a 360-degree view of risk factors.

SDOH leads to more personalized care plans. Treating the whole person across multiple SDOH categories, such as education, environment, behaviors, access and income, allow for a more accurate risk stratification and a personalized care plan that a person will more likely adhere to. SDOH are always changing. Changes in employment, education and relationships all may happen throughout the course of a patient’s journey. It is critical to incorporate workflows that allow a quick pulse of any updated to SDOH factors that may change a person’s risk factors.

There is a science to deploying surveys. If surveys are deployed at the right frequency, with question sets relevant to where a person is at in their journey, then a person is more likely to respond. However, when a person is inundated with surveys or that person receives the same question set over and over at each episode of care, then you will see participation rates and engagement drop. SDOH factors provide the opportunity to take a quick pulse of where a person is in their journey in a variety of unobtrusive ways.