Executing an Integrated Approach to Social Determinants of Health
Published in collaboration with Unite Us, Virtual Health, and Community Care of North Carolina, this report underscores the crucial need for an integrated approach to Social Drivers of Health (SDOH), emphasizing the importance of collaboration across the healthcare spectrum. Serving as a practical guide for effectively integrating SDOH management into existing operations, it provides a roadmap for understanding the SDOH model and its application, leveraging data to bridge care gaps, reducing barriers to treatment, and more. With the actionable strategies in this report, you’ll learn how to improve member outcomes and achieve long-term value.
Key Takeaways
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Introduction
Social determinants of health (SDOH) can account for as high as 80% of clinical health outcomes, research shows.¹ By now, it’s clear to payers and providers that SDOH must be addressed to improve patient outcomes and deliver high-quality, value-based care. What is still not widely understood? How to effectively solve SDOH challenges for members.
Awareness is one thing. Identifying members who need help is another. Being able to connect those members with needed resources at every step of the healthcare journey should be the standard we’re aiming for.
Organizations that are successfully addressing SDOH are using a truly integrated approach. In fact, in a recent webinar from Becker’s Natosha Anderson, Associate VP, Population Health, Blue Cross Blue Shield of North Carolina, spoke about the critical role of leveraging an integrative approach that includes SDOH, among other elements, to properly connect the dots for members.
Understand the New Model of SDOH Management
SDOH needs certainly are related to access to food, shelter in a safe environment, transportation, healthcare services, social companionship, behavioral and mental health services, financial resources, and other major human needs. But SDOH also is about smaller components of those needs. Cooking utensils to be able to prepare nutritious meals. A mattress for a comfortable night’s rest. Reading glasses to clearly see the fine print on medication. Well-fitting sneakers to safely walk for exercise. Lacking essentials like these can negatively impact a member’s ability to actively participate in supporting their own health.
When speaking with Bonnie Boyle, RN, Complex Care Manager at Innovation Care Partners (ICP), recently about ICP’s Complex Care Team, she emphasized why it was important to consider SDOH at every level of care and setting.
“A lot of times, it can seem like a little thing or a small fix, but it makes a huge impact. Some members I have helped can’t take care of themselves because they’re caring for a spouse, or they’re lacking a bed, or need help getting into a bath, don’t have kitchen utensils, or are struggling to care for their basic needs. And so ICP created our Complex Care Team to be able to step in at any time throughout a patient’s journey, identify the need, and then provide additional education or a piece of equipment (wheelchair, mattress, etc.), help communicate and coordinate with the patient’s doctor for home health orders, guide the care coordination team, or help identify and address health-related issues and other care gaps that are inhibiting the patient’s progress. SDOH is always on, and a key element for our team in keeping members out of the hospital and moving forward along their health journey.”
– Bonnie Boyle, Complex Care Manager (RN)
Boyle’s example is a perfect illustration of why SDOH cannot be a stand-alone initiative for payers. Solving SDOH requires an integrated approach that prioritizes SDOH throughout the continuum of care. It ensures that if these needs – big or small – pop up at any point in a member’s healthcare journey, they can be flagged and immediately addressed to prevent treatment from being derailed.
An Integrative SDOH Approach
In the next few sections, we’ll go through what an integrative approach looks like for SDOH. In each section, you’ll find practical data and insights, interactive questions to ask yourself and your team, and then real-world examples and advice from leading healthcare organizations around the country.
About Unite Us
Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. Through Unite Us’ national network and software, community-based organizations, government agencies, and healthcare organizations are all connected to better collaborate to meet the needs of the individuals in their communities.
