3 Ways to Leverage Social Determinants of Health Data for Value-Based Care Success

3 Ways to Leverage Social Determinants of Health Data for Value-Based Care Success

Genetics and lifestyle obviously have a major impact on a person’s health. But even more important are the conditions of the environment in which the person is born, lives, plays, learns, work and ages. These factors, which are called the social determinants of health (SDOH), play a crucial role in shaping the health outcomes of an individual.  

Creating awareness about the broader circumstances that affect the health of a certain community or a specific individual helps create and provide value-based care solutions. The patients are then treated with the respect they deserve as the care provider is able to incorporate their life experiences to improve communication and optimize health outcomes, which in turn helps reduce health care inequities.

Understanding the Social Determinants of Health 

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Social determinants of health are influenced by historical, social, political, and economic forces. Understanding these helps to recognize the relationship between a person’s health and his environmental conditions. Acknowledging the relevance and impact of social determinants of health can help care providers understand their patients better and communicate more effectively about their health, behavior, and treatments which results in improved health outcomes.

Social determinants of health is a concept that is gaining increasing importance among healthcare providers, especially the safety net providers. Those who organize and provide a noteworthy level of healthcare and related services to people benefiting from Medicaid, the uninsured, as well as the other vulnerable populations, are called safety net providers. The impact of social determinants of health on quality-of-life should be taken into serious consideration as they affect the physical and mental well-being of the concerned population.

The five major determinants of health of a population are biology and genetics such as sex and age, individual behavior such as alcohol use, drug use, unprotected sex or smoking, the social environment, the physical environment and the health services.

In more detail, specific examples of social determinants of health include:

  1. Living wages

  2. Availability of healthful foods

  3. Quality schools

  4. Transportation options

  5. Public safety

  6. Socioeconomic conditions

  7. Exposure to crime and violence

  8. Residential segregation

  9. Social norms, example: discrimination

  10. Exposure to mass media

  11. English is a second language; migrants

Community-Based Organizations in Social Innovation Efforts

One of the major challenges in the advancement of social innovation of healthcare is deciding upon how to tackle measurement, risk adjustment, and payment. As far as non-clinical care is concerned, the performance, payment, and accountability are quite unclear across most communities. To better understand and leverage ‘social determinants of health’ data for improved clinical and financial outcomes, more emphasis has to be given to investments in the latest technologies.

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At present, numerous homegrown, as well as commercial efforts, are underway to study SDOH data by unifying them with claims and clinical records. Social determinants of health are linked to clinical outcomes and analyzed to create predictive models that provide the appropriate information for upstream prevention. Nowadays, its the Community-based organizations (CBO) that offer most of the services for the non-clinical determinants of health. The future of this market is dependant upon the involvement of Community-based organizations in social innovation efforts. CBO’s activities in social innovation range from their adoption of technology, their involvement in referral programs across health plans and healthcare providers and their participation in value-based contracting arrangements.

In the coming years, CBO’s efforts are expected to give rise to companies that are better informed with socially-integrated clinical workflows and adjustments in population levels, so they can risk classifying and designing programs that are based on non-clinical datasets. Data collection and communication have key roles in computing performance and exhibiting value. It is unlikely that major Electronic Health Records (EHR) systems will develop affordable tools for consumers at the community-based organizations. So the effort is directed towards external integration that leverages the EHR data for third-party features. Attempts are also aimed at storing the externally captured data into a central record system.

Creating Awareness in the Delivery of Healthcare

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Creating awareness about the social determinant of health is a major step to leverage these factors for value-based care solutions. SDOH influence many conditions that require the care of gynecologists. These include preterm birth, unplanned pregnancies, infertility, maternal mortality and cancers of breast or uterus. Many times obstetricians, the gynecologists or other health care providers may find the patient's behavior to be irrational. To understand and treat/guide the patient correctly and effectively, it is imperative that they recognize the impact of social determinants of health, the specific ways in which their medical care gets affected due to these factors. Patients may have social identities created by the overlapping of oppression and discrimination based on gender, race, class, sexual orientation and similar factors and these become apparent in health care and outcomes.

For example, the shared history along with some personal incident of discrimination among patients of color may negatively influence their feelings about health care systems which results in them not trusting their care providers. An undocumented immigrant may avoid health care for the fear of deportation. LGBTQ patients seeking sexual health care may avoid care as they fear discrimination.

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Only with patient-centered and value-based care solutions can the provider identify the role of SDOH in clinical encounters. The care provider may discover that a pregnant patient with gestational diabetes, who was considered noncompliant as she did not check her sugars as directed, lacks stable housing. Lecturing the patient about glycemic control is effective only when her housing problem is solved. If her care provider is able to contact social service and work with them to address her housing situation, then it goes a long way towards managing her gestational diabetes. A pregnant patient being lectured about her poor weight gain is better helped if her physician can understand that she had lost her job and is unable to feed herself and her younger child properly. Referrals for food assistance or teaching her about low-cost nutritious options may be a more effective treatment here.

Screening for Social Determinants of Health

Though a lot of attempts are being made to reduce health inequities using state and national policies as well as public health initiatives, it is important that primary healthcare providers design plans to address the social determinants of health in their own clinical practices. They can provide patient-completed intake questionnaires which not only include medical history but also specific columns for capturing data about their social and behavioral determinants.

It is helpful if primary care physicians or community health care clinics come forward to initiate medical-legal partnerships which allow their patients to receive legal counsel in the same location for assistance with problems such as access to stable housing, immigration challenges, or similar legal issues that can directly impact a person’s health.


The impact of social determinants of health is not to be underestimated by healthcare providers as these factors can undermine the quality of care provided by them, irrespective of their best efforts. More priority has to be given to supporting community-based organizations in their social innovation efforts and adoption of latest technology.

Patient-completed intake questionnaires with specific questions aimed at collecting data about social and behavioral determinants can help primary healthcare providers formulate treatment plans that take social determinants of health factors into consideration.

Understanding how SDOH affects the patient and the course of treatment, helps the care providers to create value-based care solutions that are practical and effective for a particular individual.