Breaking down the barriers of SDoH: 5 proven strategies


At virtually every healthcare conference I attend, sessions discussing social determinants of health (SDoH) are the most in-demand.

While anecdotal, this is one piece of evidence that illustrates the significant impact SDoH have, as well as how much health plans and providers are clamoring to learn how to address them.

To fully address the impact of SDoH factors on health outcomes, health plans must integrate SDoH into their care delivery models and member engagement programs. This five-step approach can help plans do so effectively:

1. Build a dedicated strategy. Create a designated team that includes social workers, healthcare providers and behavioral specialists, and make time for them to find ways to address the SDoH issues that affect health outcomes. Begin discussing the types of engagement and incentive strategies you should use to encourage specific segments of healthcare populations to take action on their health. Most important, begin to identify the barriers that might be preventing or inhibiting those actions and look for solutions that could combat those barriers.

2. Align with external resources. Partner with local and national organizations to address SDoH, both to ensure that necessary services are available and to design engagement programs that address SDoH. For example, United Way of Central Jersey is addressing SDoH as they relates to oral health by promoting oral health education in schools in Middlesex County, New Jersey.

There is evidence that these types of partnerships have a positive impact on healthcare. Researchers from Yale School of Public Health, Miami University and the Scripps Gerontology Center studied Area Agencies on Aging (AAAs) — groups that coordinate social services for older Americans — in counties across the U.S. The research found that AAAs that maintained informal partnerships with healthcare and other organizations had significantly lower hospital readmission rates. On the other hand, counties whose AAAs had lower instances of community partnerships had higher readmission rates.

3. Identify the need. Plans can use data analysis to discover areas where segments of the population lag behind, determine the type of assistance they need, and then act accordingly. For example, a plan may want to encourage diabetic members to get their A1C screening. The first step is to identify the social factors preventing these members from getting their screening and design a program to help them overcome those factors. Members undoubtedly have varying healthcare and social needs, and the idea is to build a program that addresses both.

4. Develop appropriate incentives. Continuing the example from the previous point, a significant portion of this diabetic segment of the population might lack access to transportation, which prevents them from getting their A1C screening. If so, a plan could partner with a local transit agency or rideshare service such as Uber or Lyft and offer members free or heavily discounted rides to the clinic to get their screening.

Plans and providers can work together to determine the types of incentives that encourage members to take action for their own well-being. Designing the incentive is only half of the battle, though. Plans also need to work to make members aware of the programs and services that are available to help them take action on their healthcare. This is all about reaching members in their preferred channels and encouraging them to actually take advantage of the service.

5. Offer financial resources. While incentives help encourage members to take short-term actions, offering financial resources helps them maintain their long-term health. This may include a range of options from shopping tools and co-pay assistance to housing assistance, job training, career placement services or food programs.

Addressing SDoH factors is a challenge, and offering one-time incentives for a single healthy act is not a strong long-term strategy. The end goal is access to care, but incentivizing that care activity won't help if you're not also addressing all the barriers that might stand in a patient’s way. It’s less about the one-time incentive for single healthy act and more about how plans can help members solve for SDoH. At that point, it's about awareness and activation — making members aware of the programs and services available to them, and then making sure they actually use those programs.


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