A Five-Point Plan to Address SDOH

By Joe Nicholson III, DO

Social determinants of health (SDOH) have been talked about for years, but the COVID-19 pandemic has proved beyond a doubt how powerfully they impact patient outcomes. Data shows that socioeconomically disadvantaged populations globally are over-represented among COVID-19 cases and deaths. Yet, such data may only be the tip of the iceberg.

Over the past 18 months, the number of patients receiving preventive services has dropped drastically. As a result of delayed care, many experts predict we soon will see an increase in severe and late-stage diagnoses. That means more complex and costlier situations in terms of economic, physical, and mental health impact. SDOH such as food insecurity, lack of transportation, job uncertainty, and medical deserts compound the influence of care delays and can affect an astounding 80% of patient outcomes.

So the question is this: How do we address SDOH to resume preventive care for those who need it most?

Addressing SDOH is complicated. It cannot be solved without collaboration. The old adage “It takes a village” truly applies here. While providers often focus on putting sophisticated population health technologies in place to grasp SDOH, data is just one piece of the puzzle. Equally important is a well-defined and collaborative action plan.

SDOH mitigation in action

Moving the needle on SDOH and outcomes is not easy, but reducing barriers to care is possible when providers, payers, and community-based organizations (CBO) team up within a supportive framework. For an example I can speak to directly, Valley Organized Physicians (VOP), a Texas independent physician association that CareAllies manages, set about to lessen SDOH barriers for its patient population even before the pandemic struck. We worked together using the following flexible, five-point framework:

Identify goal. In this case, the goal was to recognize and attend to the SDOH affecting patients’ health.

Assess current state. VOP recognized that high poverty rates among its patient populations were driving undesirable health behaviors.

Leverage joint expertise and capabilities. VOP partnered with CareAllies to gain deeper insights through data and analytics, and to extend its providers’ workflows with an interdisciplinary team of health advocates.

Pilot a solution. CareAllies used predictive algorithms to identify patients at risk for an SDOH gap, and VOP providers referred patients into the program when gaps were identified at the point of care. Then the interdisciplinary team of social workers, nurses, dietitians, and others worked with patients, providers, and CBOs to resolve the identified gaps. Direct outreach to patients helped further define each individual’s need, at which point each person was connected with an appropriate solution to address their SDOH concern.

Measure and adapt. The team measured and tracked SDOH gaps, closures, and outcomes and adapts as needed. From July through December 2019, 733 patients were identified and referred to SDOH resources. Then, as the pandemic began to unfold, the team recognized that many patients were at high risk for COVID-19 due to SDOH gaps. Therefore, they pivoted the SDOH program. The team developed a questionnaire to identify specific pandemic-related SDOH needs, and reached out to patients proactively to assess their situations.

The fact that CareAllies already had an SDOH program in place helped us adapt quickly to patients’ new challenges during the pandemic—including many of the unusual circumstances created by COVID-19. For example, more than half of the Medicare Advantage patients contacted reported needing help bathing because their caregivers could not attend to them during quarantine.

Not surprisingly, referrals to the SDOH program continued during the pandemic. In 2020, more than 1,300 patients were identified as needing SDOH resources.

New opportunities

It is humbling to realize that there is a limit to how much providers can help patients clinically. Our best care plans are for naught if SDOH prevents patients from complying with them. So, as the south Texas story illustrates, a partnership approach to SDOH is essential. No single organization can solve every SDOH need. If we hope to improve patient outcomes, we must work together to identify SDOH problems, then design strategies capable of supporting people locally.

It is also important to evolve SDOH strategies over time. Expecting to launch a perfect solution immediately is not realistic, but it is feasible to start small. Develop relationships with local food banks, drug treatment centers, shelters, and other CBOs on behalf of patients. Likewise, look for more impactful ways to connect with patients. Although providers must always consider patients’ potential technology limitations, engaging patients through texting, instant messaging, and video conferencing solutions can be effective options.

The pandemic has presented unprecedented challenges that are not likely to disappear for quite some time. It has also revealed the undeniable link between SDOH and patient outcomes. In so doing, however, it has illuminated a path toward more equitable care. We now have an enormous opportunity to apply the lessons of COVID-19 to mitigate SDOH and create a better healthcare future.

Joe Nicholson III, DO, is chief medical officer at CareAllies.