5 Examples of How Social Determinants of Health are Being Used to Improve Wellbeing

“Social determinants of health” (SDoH) are much discussed in medical facilities and managed care companies these days. According to Healthy People 2020, SDoH are “the conditions in which people are born, live, learn, work, play, worship, and age, which affect one’s health, functioning, and quality-of-life outcomes.” Highly-cited statistics state that SDoH impact up to 90 percent of a patient’s outcomes.

Healthy People 2020 emphasizes the importance of SDOH by including “create social and physical environments that promote good health for all” as one of the four overarching goals for this decade. The five key areas (determinants) addressed by Healthy People 2020 are:

  • economic stability (employment, food insecurity, etc.)
  • education (early childhood education and development, language and literacy, etc.)
  • social and community context (discrimination, incarceration, etc.)
  • health and health care (access to primary care, etc.)
  • neighborhood and built environment (access to foods that support healthy eating patterns, crime, and violence, etc.)

At the time of the Healthy People 2020 Midcourse Review, 15 of 33 (45.5%) of the measurable Social Determinants of Health objectives had improved or met/exceeded target, while 10 out of 33 (30.3%) of the measurable Social Determinants of Health objectives got worse or didn’t change. The remaining 8 objectives were informational. 

Health payers are exploring creative ways to improve the SDoH among their members. For example, Cedars-Sinai just revealed that they will be offering grants to over 100 different programs across Los Angeles County to target housing and homelessness issues, access to community care clinics, and other programs working to address the SDoH. A Kaiser Family Foundation survey determined that 91% of Medicaid managed care plans used SDoH data to steer their interventions.

Boston University + Sharecare

Boston University’s School of Public Health recently revealed that, in a 5-year partnership with Sharecare, they are developing a Community Well-Being Index. The index will unite the data that BU and Sharecare previously collected regarding physical activity, genetics, lifestyle choices, as well as other environmental factors such as traffic, weather, food insecurity, and crime. Other partnering organizations will add more data, including grocery transactions, lab results, and prescription medication fulfillment. The data will be utilized in the creation of public rankings of healthy communities and states. The data will also help guide consumers towards local resources such as fitness facilities, and to deliver targeted wellness tips. Clients of Sharecare, including Walmart, Lockheed Martin, and the Medicaid system, will use the index to understand their populations better and create targeted strategies that will better wellbeing.

Northwell Health + NowPow

Northwell Health has partnered with NowPow, a startup that’s designed a platform to aid in addressing the SDoH and more effectively connecting patients to community-based organizations. With NowPow, Northwell will start providing the company’s services to roughly 1,2000 Medicaid patients who are part of their Health Home, a care coordination program providing support services for patients with significant behavioral health conditions. NowPow’s software platform will use diagnostic codes in health records to distinguish patients’ most critical needs. Matching logic and evidence-based algorithms will be used to suggest community-based resources. The software will apply patients’ geographic location, eligibility for services, and languages spoken to enhance the referral process. Northwell has also partnered with Pieces Technology to create a social vulnerability index for patients and communities.

AdhereHealth + Papa

AdhereHealth, a healthcare technology company, has joined forces with Papa, a companionship platform for the elderly, blind, and disabled. Together, the two companies will pool resources to tackle SDoH, such as loneliness, food insecurity, and transportation. Analytics and clinical workflows will help lead Papa Pals to evaluate an array of SDoH issues such as grocery shopping, housing chores, and transportation. AdhereHealth will employ “Papa Pals” to provide face-to-face support to people at risk for poor health outcomes. The partnership is immediately accessible to over 20 million American’s covered by Medicare Advantage plans.

America’s Health Insurance Plans

In June of 2019, the lobbying group America’s Health Insurance Plans (AHIP) unveiled a new health initiative, Project Link. The project will encourage health insurers to collaborate on social issues and obstacles to wellbeing. Members will collaborate and lobby for policy changes necessary to focus on social issues.

Meals on Wheels

Sometimes a straightforward change in policy can have a massive impact on the population’s SDoH. For example, in partnership with Meals on Wheels America, researchers from Brown University and West Health Institute developed a smartphone app for drivers to report concerns about clients while delivering meals. Those alerts were forwarded to care coordinators, who intervened and referred patients to applicable health or social services. During the 12 month study period, drivers in the two sites of San Diego, CA, and Guernsey County, OH, reported a total of 429 alerts for 189 unique clients. Fifty-six percent of the alerts were related to observed changes in wellbeing, 12% concerned patient self-care, and 11% involved patient mobility. Those alerts triggered 132 referrals from care coordinators. If executed nationwide, this model could address the social needs of nearly 40,000 senior patients.