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The Role of SDOH Strategies in Population Health


As the healthcare field races toward value-based, whole-person care, social determinants of health (SDOH) become a key element of the conversation. The industry is paving new paths. We’ve learned that incorporating SDOH into care and payment models is critical, but we’re still trying to figure out what that looks like and how to get everyone on the same page.

This fascinating topic was the subject of a roundtable discussion hosted by Mark Hagland of Healthcare Innovation. The panelists included Dr. Marshall Chin of the University of Chicago Medicine, Sarah C. DeSilvey of the Gravity Project, Lindsey Haase of OCHIN, and Dr. PJ Helmuth.

Building off of their vibrant discussion, we’ve published a whitepaper diving deeper into the role of SDOH in population health. This whitepaper outlines the critical need for incorporating SDOH in care and payment models and features insight from industry experts exploring:

  • Effective, evidence-based strategies for addressing the primary challenges of SDOH
  • Technology’s role in supporting population health strategies in the next era of healthcare
  • The complexities around the move towards value-based care and caring for more vulnerable populations

What are the five domains of Social Determinants of Health?

Social determinants of health are the environmental factors in a person’s life that affect their health, quality of life and well-being. They typically fall under one of these five domains proposed by the Office of Disease Prevention and Health Promotion:

  • Economic Stability: Poverty can greatly impact a person’s ability to access care and other components of a healthy life, like nutritious food and housing. Some initiatives designed to help people find and keep work and access resources, include employment programs, career counseling, child care, and food and housing payment programs.
  • Education Access and Quality: Higher levels of education are linked with better health and longer lives. Helping kids graduate high school and go to college can increase their likelihood of getting safe, high-paying jobs, and avoiding health problems and stress.
  • Healthcare Access and Quality: Barriers to care include a lack of insurance coverage, transportation issues, technology demands, and minimal available providers who meet the patient’s linguistic and cultural needs. A wide range of initiatives and technology solutions can help break down these barriers.
  • Neighborhood and Built Environment: One’s neighborhood can introduce health and safety issues, such as high rates of violence, exposure to air pollutants, and unsafe water. Improving these environments with additions like safe sidewalks, crime-reduction programs, and policy changes to support clean air and water is essential.
  • Social and Community Context: Positive relationships with friends, family, co-workers, and community members can help mitigate negative environmental effects and promote behaviors for health and well-being. Some individuals don’t get this support, and aspects like counseling, family time, and community support for health behaviors can help in this domain.

What is the impact of addressing SDOH on population health?

Abundant research for each of these domains and topics has given us immense insight into the value of SDOH initiatives. For example, housing instability is associated with higher rates of fair or poor caregiver and child health, child lifetime hospitalizations, maternal depressive symptoms, and household material hardships, such as foregone care or food insecurity. Programs like tenant-based voucher programs and permanent supportive housing (PSH) models can improve housing stability.

Other initiatives that have gathered evidence include policies on smoking, lead paint and water quality, resources for addressing poor air quality and pests and housing modifications for adults with functional living challenges. Similarly, strong evidence has emerged for aspects of all five domains of SDOH. The potential for SDOH endeavors is huge. They can have a vital role in improving health outcomes and well-being for all.

Why are Social Determinants of Health important?

The majority of the time, patients aren’t in contact with their providers. SDOH often determine what happens in that time, and they make up as much as 50% of county-level variation in health outcomes. They influence whether the patient can get to their appointment, pay for it comfortably, follow their treatment plan, and stay in generally good health.

Research shows that healthcare is a relatively weak determinant of health, with outcomes primarily driven by health behaviors instead.

Social and economic factors shape these behaviors. For instance, children born to parents who haven’t completed high school are more likely to live in a setting with health barriers like a lack of access to safe housing, playgrounds or libraries. If health and non-health systems don’t address these factors, they aren’t truly addressing the health and well-being of the whole patient.

Many clinicians have long wanted a system that successfully addresses social determinants of health, but it hasn’t been a priority for the industry as a whole. One positive outcome of the pandemic was the increased awareness of SDOH as a vital part of improving outcomes. It highlighted various structural inequities like racism and privilege, building up public momentum for the severe impacts of social risk factors. It showed us the need for connected communities that address systemic and individual barriers and their relationship to one another.

The pandemic became a stress test for many, revealing how our approach to healthcare doesn’t work well as a system. Physicians like Dr. Helmuth saw the effects of being disconnected from patients in stark relief. All of a sudden, he couldn’t get in touch with them. Some couldn’t access the technology needed for telehealth appointments or biometric data collection, and many new methods of care didn’t offer appropriate reimbursements for clinicians. The pandemic quickly revealed how many people risk losing access to care whenever a stressor occurs.

Now that this catalyst has revealed such a large disparity, we’re pivoting toward developing evidence-based solutions to drive health equity and better outcomes. Governments and markets are bringing regulations and incentives to support this work, and promising tools have emerged. Since addressing SDOH calls for a drastic shift in how we approach care, the industry has some growing pains to work through.

The Primary Challenges of SDOH

Integrating SDOH into care is something of a new frontier. Hagland compares it to the chaotic early days of cars and phone systems. Car makers had gas and brake pedals in different places and were customizing each car, until Henry Ford standardized them with the assembly line. Until the Bell System came around, the first phone companies would only allow you to call someone if you were both subscribed to the same service.

These initial versions were messy and far from cohesive, because people were still trying to figure things out. Addressing SDOH creates a similar problem, with large-scale, systemic requirements and a lack of agreement across systems within and outside of the healthcare system.

Systemic Change

Adjusting care for SDOH calls for a comprehensive chain of interaction connecting primary care physicians (PCPs), patients, community organizations, internal documentation, clinical tools, and more. With so many different entities, misalignment occurs in several places:

  • Payment models: Although payment models are shifting toward value-based care, it can be a slow process. Traditionally, payment systems haven’t been aligned to incentivize this overarching type of transformation. Widespread use of SDOH will likely depend on carefully considered incentives from payers.
  • Providers: Providers already have a lot on their plates. To avoid additional demands and physician burnout, we need easy-to-navigate tools and teams to support SDOH initiatives, such as resource locators and care management programs. For care management, TimeDoc Health offers different connected solutions with skilled teams and monitoring tools.
  • Community-based organizations: Many of these organizations can fill the gaps, but they don’t connect with the larger healthcare system. To address SDOH, these systems must integrate social services and healthcare.
  • Patients: SDOH can make it hard for patients to access the healthcare system in the first place. True population health management has to include everyone, even those who haven’t entered the system. It requires considerable outreach to meet patients where they’re at.

Aligning these needs demands a system that connects at all levels, from one-on-one patient care in the medical setting to overarching connections and infrastructure that promote well-being and health.

Dr. Chin points out the importance of truly prioritizing health improvements for all. He borrows the analogy of taking a flight, which offers a salient example of class systems — business, economy, first class — that impact your experience. At the end of the day, everyone still reaches their destination and receives an adequate outcome. In healthcare, that floor has yet to be established.

Dr. Chin also cautions against viewing SDOH solely as a cost-saving initiative, because that will take considerable time. Instead, it should be a conversation about health equity.

Standardization of Data and Language

Another significant problem is the lack of consistent terminology and data collection methods. Different entities are doing different things to tackle SDOH, and this lack of standardization can inhibit research, policy discussions, and innovation that could help address barriers and risk.

Dr. Helmuth recalls a time when working with the Center for Health Information and Analysis (CHIA) in Massachusetts. The group was looking into SDOH data from across the state and seeing how it could help with tasks like identifying social risk factors and comparing systems. One of the first roadblocks the group experienced was naming and defining different components. With various hospitals collecting different data, CHIA wasn’t sure how to aggregate or analyze it. Simple nomenclature became a significant barrier to their work.

One group making great strides in this area is the Gravity Project. This national public collaborative is working on getting everyone on the same page regarding SDOH data standards and information-sharing across local and federal levels. Some considerations we must keep in mind with SDOH data include:

  • Customization: While many elements can be standardized, others are best tailored to specific patients or providers. What works in a rural practice may not work in an urban one. Standards development has to be aware of these nuances.
  • Protective factors: Social risk factors are a big part of discussing SDOH, but protective factors are valuable, too. Social determinants must include positive and negative aspects.
  • Artificial intelligence (AI): AI fuels some of the biggest innovations in healthcare, but we must be sensitive to the fact that objectivity isn’t built-in. Humans create algorithms, so their biases can become part of the code. Those creating AI solutions must address inequality by design.

Infrastructure in Communities and Health Systems

Mobilizing resources related to SDOH depends on the infrastructure in place through communities and health systems. For example, without accessible broadband connections or reliable telephone connections, patients may not be able to access digital resources in the medical system like telehealth. The right infrastructure can help relieve the burden and complexity and lay the groundwork for vital SDOH initiatives.

Much of this infrastructure comes from the need to make big changes in an already-strained healthcare system. We must identify the role of different players, including the PCP, the patient, the care team, and community resources to ensure everyone works at the top of their license and puts their unique skills to work. Health systems can’t expect PCPs to take on the lion’s share and add these complex requirements to their workloads.

Many SDOH topics are sensitive and require specialized training and time.

A team-based approach is an excellent option, but it can still pose a challenging transition without the proper infrastructure. Payment systems could better support the costs of care teams and other SDOH initiatives by calculating reimbursement models to include infrastructure demands, such as software, training, and personnel. Needs like this must be included in the transition to value-based care.

Health systems and communities are vast. What may seem like a simple change might require the coordination of 10 units. Building the infrastructure calls for organization-wide transformation that’s cognizant of each person’s role, cultural ideas of care, and the need for additional resources.


Download this Whitepaper Perspectives on the future of health equity and advancements into the new era of care.  

The Gravity Project

One group making crucial progress in the world of SDOH is the Gravity Project. This large public collective is working to align the language and standards we use for data collected from clinical and social care settings.

The Gravity Project is a consensus-based initiative that develops standards for social terms and risks. For example, it creates consistency across terms like food insecurity, transportation access, and housing instability, including subtypes.

This growing list aims to build a language that mirrors how real clinicians, teams, and community-based health workers and organizations care for patients and clients. The Gravity Project also ensures every data element is defined with evidence-based language and created with panels of technical experts.

This information and terminology will be vital in developing screening tools, critical diagnoses, policy discussions, patient-centered goals and core interventions that align with local and federal programs.

Hopefully, with more standardization, providers can quickly select recommended tools and resources to address identified social needs. Use cases might include direct clinical care, population health, and alignment with quality measures.

With the knowledge the Gravity Project is building, researchers can look at true population health data, driven from the personal level and aggregated at the population health level.

More data should help reveal community drivers like food access, transportation, and other elements that patients can’t overcome without structural resources.

SDOH and Value-Based Care

As you’ve likely noticed, SDOH strongly connects to value-based care. SDOH is important in public health discussions about payment models and connecting overall health status to the medical components of the healthcare system. Since we currently have what Hagland calls a “sickness care system,” the act of adding value-based care is akin to fueling the plane in midair or trying to turn the ship around. The system is already in place, so adjustments are difficult.

Leaders like the Centers for Medicare and Medicaid Services (CMS) have provided signal direction by prioritizing health equity in Medicare and Medicaid. Private plans are creating better incentives for value-based care. Still, our current healthcare system wasn’t designed to optimize health. It has competing financial interests and is often profit-driven. Moving away from fee-for-service isn’t a silver bullet, either — it’s just one part of building the path forward.

For instance, payment reforms shouldn’t happen for reform’s sake. They should be built to support and incentivize care transformation and address the medical and social needs to advance health equity. Dr. Chin suggests we can look at payment in three different areas:

  • Upfront payments: Consider how initial payments occur, with models like per member per month and global caps. These payments need to factor in infrastructure support for data and personnel.
  • Measurement: Payment models must identify how systems will be rewarded for meeting certain metrics and which metrics drive social determinants.
  • Social risk adjustments: Providers who serve vulnerable populations often get hurt by payment systems that don’t factor in the effects SDOH have on outcomes. Payment systems must adjust for this risk.

Hagland references issues with the Medicare Shared Savings Program (MSSP), where providers would get tripped up by evolving benchmarks. For a more successful program, they wanted continuous rewards and benchmarks that didn’t become harder to meet over time.

This issue can be complex, and CMS must avoid disadvantaging providers who care for vulnerable populations. SDOH should be baked into incentives to ensure providers caring for the most vulnerable populations or those with the greatest social needs are sufficiently rewarded.

Dr. Helmuth also brings up the issue of risk, with the example of an accountable care organization (ACO) trying to identify the best investments. The ACO might try to decrease utilization with care coordination or care management programs or increase the budget itself with a better coding program.

Many SDOH initiatives like these rely on identifying high-cost patients and deploying resources to decrease expenses, but there isn’t a lot of real-world data to show whether they would provide a return on investment (ROI) and how long that would take. Fortunately, this evidence is quickly emerging, with some of the strongest support for ROI going toward efforts in housing and nutrition.

Unfortunately, without incentives or assurance, the adoption of value-based care will likely be slow. Dr. Helmuth points to the implementation of electronic health records (EHRs) as an example. EHR adoption reached nearly 90% in just over a decade, but not without the help of incentives. He says the health system found the right mix of “carrots and sticks” to push adoption, and we can’t move forward in addressing social risk factors until we identify the right carrots and sticks for value-based care programs.

The Future of SDOH and Population Health

While there’s still a lot of work to do, SDOH is an interesting and promising area of health care, and the panelists agree we’re in a time of exceptional opportunity and growth. The industry is moving in this direction and fine-tuning its approach to patient needs and connected communities.

Clinicians understand the need and value, and the field is moving fast. As Dr. Chin suggests, getting a start on SDOH can even serve organizations from a self-interested perspective. Early adopters can reap the benefits first and stay ahead of legislation.

We still have many questions to answer, like who our community health workers are, how they should be trained, what everyone’s role is, which non-health elements should be owned by the health system and where care will happen. In the coming years, we’ll figure out how infrastructure in the health system will interact with the community without reinventing its roles.

Like the first cars and phones, laying the groundwork can be rough and messy, but these paths eventually evolved into the sophisticated, dependable systems we use today.

It’ll take a high level of system integration and coordination to get there, making this an especially exciting time in health care.

SDOH Initiatives to Introduce the Next Era

TimeDoc Health is committed to bringing modern care to more patients and providers. Our care management solutions include chronic care management, remote patient monitoring and behavioral health monitoring.

Our clinically trained care coordinators can help you address SDOH in your patients by acting as an extension of your team, and our EHR integrations make it easy to use clinical findings within physician workflows.

We know the power of addressing SDOH, and so do our users. From reduced costs and increased reimbursements to better outcomes and patient retention, TimeDoc Health has helped all types of practices reach their population health goals.

To learn more about the platform, contact us to request a demo.