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The Crucial Role of Social Determinants of Health and Opportunities for Investment

Insights by Empactful Capital Special Advisor, Terry Fouts, MD. Terry served as a CMO and senior executive to multiple healthcare organizations, he also volunteers as a patient navigator at the University of Colorado Health Outpatient Clinic.

The Key Role of Social Determinants of Health in Patient Well-Being

Social determinants of health (SDOH) may be the most “vital” of all vital signs. Unfortunately, healthcare providers are not always aware of these issues as they apply to their patients, even though they may be the most impactful aspect of their health. SDOH are often not obvious during an encounter and patients may be reluctant to share basic social needs with their providers.

Defining SDOH

The World Health Organization (WHO) describes social determinants of health as the “non-medical factors that influence health outcomes. They are the conditions into which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”

Some examples of SDOH include:

The World Health Organization (WHO)

The Centers for Medicare and Medicaid Services (CMS)

The Commonwealth Fund

- ​Income and social protection - Education - Unemployment and job-security - Working life conditions - Food insecurity - Housing - Early childhood development - Social inclusion - Structural conflict - Access to affordable health services of decent quality

- Food insecurity - Housing instability - Transportation needs - Utility difficulties - Interpersonal safety

- Housing - Home modifications - Nutrition - Transportation - Care management - Counseling on legal and financial issues - Social isolation and loneliness

Evaluating the Impact of SDOH on Overall Health Outcomes

% of SDOH Influence on Health Outcomes

Practically everything that a patient encounters outside of the provider-patient encounter itself will have both a health and an economic impact on that individual, their community and the health delivery system responsible for their care. Numerous studies suggest that SDOH account for between 30 to 55% of health outcomes, exceeding the contribution from the health sector itself. Some authors have suggested that medical care was responsible for only 10-15% of preventable mortality.

Current Level of SDOH Screening and the Impact of SDOH on Risk-Bearing Entities

Taking into account that 80% of the influences of health outcomes arise outside of the defined healthcare encounter, any risk-bearing entity would ignore SDOH at their own peril. Screening for and intervening with SDOH is complex, time consuming and at times seen as invasive by the patient. Additionally, if these are to be acted upon, multiple resources need to be engaged which are often based on many factors such as payer source, geography, language, patient preference, and availability.

Many health systems have devised their own screening tools and patient engagement methodologies. There are also independently developed and verified tools for use. These are then integrated into their electronic medical record (EMR). Case managers, care managers, transition of care nurses, social workers and patient navigators can then use this information to connect with the patient and start the process of remediating the identified needs. The initial screening process can take up to 90 minutes per patient although many tools gather the basic information more quickly.

The challenge is to engage the appropriate resources for that particular patient and effectively follow up to ensure that the engagement has been effective.

Upcoming SDOH Intervention Mandates

In addition to some very effective efforts by health systems to institutionalize SDOH screening, CMS has entered the arena with the requirement that all hospitals reporting to the Inpatient Quality Reporting program submit two brand new measures : SDOH-1 and SDOH-2 starting in 2024. These apply to admitted patients 18 years old or older.

  • SDOH - 1: Of all the patients admitted to the hospital, how many were screened for SDOH?

  • SDOH - 2: Of all the patients admitted to the hospital who received SDOH screening , how many were identified as having one or more social risk factors?

Exploring Available Return on Investment (ROI) Estimates for Implementation

Is there an ROI for these activities? The Commonwealth Fund published an extensive look at this issue in their Guide to Evidence of Health-Related Social Needs Interventions: 2022 Update. The below points highlight some of their key findings:


Providing homeless patients with supportive or transitional housing reduced ER visits a median of 29%, hospital admissions by a median of 31% and a modest reduction on total health care costs in 2 studies, but no significant reduction in 5 studies.


In eight studies home delivered meals reduced ER visits a median of 36%, hospital admissions a median of 44% and overall costs were a median of 16% lower.


Care management often addresses multiple social needs and can integrate medical and social service interventions across a wide team of professionals. This meta analysis encountered a number of different results depending on the model, but examples are reduction in ER use ( 7 to 80%), reduction in readmissions(17 to 76%) and reductions in health care costs ($124 to $773 pmpm) with intervention costs ranging from $81 to $417 pmpm.


These results showed wide variety of outcomes. The provision of non-emergency transportation is often the first need identified and often results in increased compliance with clinic visits. One study showed a cost of avoidance of $3423 PMPM for dialysis patients and $792 PMPM for diabetic wound care patients as a result of the provision of non-emergency transport.


These services include dealing with landlords, payers, utilities etc. Often patients, especially low income patients, are unaware of coverage opportunities and therefore it is in the providers’ interest to investigate all possible payer avenues. Preservation of utility coverage can obviate illnesses induced by extreme cold or heat.

Ideal solutions address the following touch-points:


  • Robust, dynamic and individualized screening

  • Integration with existing screening tools, resource bases and CMS SDOH requirements

  • Integration with community resources and third party vendors of SDOH services

  • Integration with provider systems

  • Population wide, not just inpatients or those seeking care currently

  • Reporting capabilities to drive engagement strategies and quality improvement activities

  • These processes result in improved outcomes for the patient, provider and payer

Incentives for Health Systems to Manage SDOH

Screening embodies a significant area of need.

Most screening occurs because of an encounter or a single identified need, most often transportation. Transportation however is often the gateway to identifying other needs. Much of this is done by case managers, social workers, discharge planners, or patient navigators. The challenge is to develop an application that could automate this function across multiple data sets including claims, geography, access to pharmacy, food, transportation, payer sources, ethnicity, medical history, current screening tools etc. Often lack of compliance with scheduled appointments or failure to obtain prescriptions are indicators of transportation needs. Using these data to cross correlate with available resources to generate targeted work list for the navigators would be extremely useful. Much of the ROI data cites the cost of the intervention. This approach would lessen the cost of the intervention thereby improving the ROI of the activity. It would also allow the work output to be triaged for urgency and assigned to the appropriate professional. The result would be more patients effectively screened and engaged utilizing fewer resources.

Putting resources directly into the hands of the consumer could short circuit the need for human intervention.

An application should provide the consumer the ability to self screen for SDOH needs and then provide appropriate resources directly to the consumer. These resources would be appropriate to the insurance of the consumer, the geography of the consumer and the cultural requirements of the consumer.

Automated workflow would improve these activities because often there is a need for multiple person-to-person follow up encounters.

This activity should be able to trace compliance For example, did the patient actually get signed up with food delivery and generate follow up scheduling and reminders? Allowing SDOH resources direct access to the EMR would short cut a lot of inefficient back-and-forth communication that is in common use.

Statistically following outcomes both clinically and from patient reported outcomes, satisfaction and life improvement would justify the efforts involved in solving for SDOH.

This activity would enable statistical evaluation of quality not only for the program but also for the vendor partners and community resources. This quality feedback initiative would drive stronger integration between providers and SDOH resources.

In conclusion, focus on Social Determinants of Health is an integral and important part of the healthcare delivery landscape. Risk-bearing entities as well as public health and population health managers will do well to excel at this capability.

Terry Fouts, MD

Special Advisor, Empactful Capital

Former CMO and Senior Healthcare Executive


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