As the healthcare industry shifts to a value-based reimbursement model, healthcare organizations are focusing their attention not just on making patients better—but preventing them from getting sick in the first place. Gaining a better understanding of the social issues that affect a person’s health is one of the first steps in doing so.

While we know that patient outcomes can be materially impacted by non-clinical factors, such as social determinants of health (SDoH), the industry’s strong focus on medical factors have long pushed SDoH to the backseat. However, it’s clear that population health management is most effective when it is comprehensive and community-based, extending beyond the walls of a single-care establishment to encompass all relevant services, including medical, behavioral and socioeconomic factors. But what will truly make a difference to members and patients is being able to prescribe SDoH solutions in a normalized manner to consistently improve outcomes.

As organizations transition to value-based care and make decisions on the interventions and level of intensity needed to address an individual’s SDoH, the ability to measure results—and draw insights from those results—is critical. What will truly put social determinants on the map is developing evidence-based care in the social realm—with the same rigor applied to common terminology, data infrastructure, and a workflow that supports demonstrable and repeatable success.

Still, elevating the importance of SDoH is difficult. The environment is complex, with many types of disparate organizations that must be coordinated to improve the physical health of patients. It’s challenging to capture descriptions of social factors and the interventions that address them, making it difficult to find a common language or develop a shared body of knowledge. Without a clear path to payment, organizations have little incentive to push forward. And because social determinants vary from region to region, the best practices of one organization may not be the same for others.

So are these social factors significant enough to deserve more attention? The answer is a resounding yes. In fact, they matter even more in today’s healthcare environment as organizations across the nation shift to value-based care.

A Path Forward

Value-based care involves connecting a variety of different medical encounters in a protocol to treat a condition successfully. But what it doesn’t take into account is that every time a patient leaves the controlled environment of a medical provider, they enter a social context that must be grappled with. It’s here that SDoH come into play. We need to be able to bridge the gap between the medical and social realms to get patients where they need to be.

To get there, healthcare providers need a care model that goes beyond the reactive management of care—simply healing people who are sick—to a proactive model that prizes prevention. This approach requires that providers understand the patient outside the medical office—and be able to address their social issues using partnerships within the community that can help keep the patient on track. By creating a community-based care plan that connects medical, behavioral and social service providers, providers can coordinate what they are going to do for a patient in the future—not to mention give everyone a say in how efforts will be harmonized.

Information from the medical, behavioral and social service providers will not only yield insight into factors determining health and begin proposing solutions, but it will also begin the process of developing interventions that can be applied to the broader population. Over time, providers can normalize what actions are being taken, measure results, validate care steps and build models that determine efficacy. This will lead to an empirical set of evidence-based activities for social determinants of health that can be prescribed at the point of care. With all this in place, the end result will be a more efficient and effective collaboration with a measurable reduction in admissions and emergency department usage.

The shift to value-based care and population health management is an opportunity for all to raise awareness about SDoH and promote care planning, coordinated care teams and common tools that will enable providers to treat the patient as a whole person instead of solely their medical conditions. Laying a foundation that is empirically based will pave the way toward evidence-based care for SDoH.

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