Three steps to identify and address social determinants of health

Social determinants of health (SDoH) reflect a wide variety of factors, including where people live, their education level, their occupation, and their ability to access support networks. SDoH can significantly impact a person's wellbeing and can act as a predictor for conditions like heart disease, stroke, and diabetes, according to the CDC.

Given the tremendous impact of SDoH, it’s no surprise that many health insurance plans have implemented programs, solutions, or resources that assist with food delivery, housing, transportation, social services, and other needs. But despite having these resources in place, many organizations face obstacles in identifying social barriers in the first place, creating workflows for resolving these barriers, and establishing a mechanism for ongoing monitoring to ensure interventions have taken place.

How can healthcare organizations overcome these challenges? Outlined below is a three-step strategy for better identifying and closing the loop on SDoH.

1. Uncover when someone has a social determinant barrier

Care teams often struggle to reach, engage, and enroll vulnerable populations in care management through traditional telephonic outreach, since many members don’t have a home phone, may frequently change addresses, and are often unable to pick up calls during business hours. But with a digital health management platform, organizations can capture day-to-day information on member needs and behavior that they wouldn’t have access to otherwise.

For example, health plans should use technology that enables secure mobile messaging, allowing members to ask questions on their own time. Health plans can also deliver mobile surveys that identify social determinant factors. These added interactions ultimately create more opportunities for health plans to cater to members’ individual needs and build long-term relationships.

2. Surface social determinant barriers to the care team

A digital health platform can generate unique and valuable data, more frequent touchpoints, and build a human relationship that uncovers nuanced insights. But how can organizations leverage technology to get this information in front of the right people at the right time? A digitally enabled workflow can surface these insights while helping care teams find the signal in the noise. In the following scenario, we review how this technology should work.

First, the member engages with mobile health education that equips them with strategies for engaging with their care team and empowers them to speak up about their needs. The next evening, they open their phone and answer a quick survey on their medication adherence.

The member’s response is sent to the care manager in real time as a priority action item in their digital workflow. Without needing to play phone tag, the care manager sends a quick message to the member to follow up. By lunchtime, the care manager has uncovered that the member doesn't have a ride to the pharmacy. The care manager then offers to connect the member to the health plan's transportation services.

3. Triage the member to the right resource or benefit

Health plans are investing in new partnerships as well as new staff members and resources to address a broader range of member needs. But these resources cannot be used effectively if members aren’t connected to them in the first place.

As the first point of contact with the member, care managers should be equipped with a platform that enables them to seamlessly triage member needs and connect members to the right services. These services could include specific health plan programs and resources, as well as specialized staff such as social workers, behavioral health specialists, dieticians, or pharmacists.

By streamlining these resources through a digital health platform, the care manager can follow up with each staff member to confirm that the member’s social barriers were addressed. The care manager can also provide ongoing follow-up and support to the member to make sure they have the health guidance and resources they need.

Visit Wellframe.com to see how your organization can leverage digital channels to better identify and address social determinants of health.

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.