For those who have worked on the healthcare frontlines—in hospitals, provider offices, and even patients’ homes—the challenges of social determinants of health (SDOH) have been less of an emerging trend or buzzword and more of a longstanding problem that desperately needs to be addressed.

Health plans have also grappled with this issue on a massive population scale, oftentimes crossing large swaths of states, regions, and the country. Historically, health plans have been limited in their ability to intervene due to rules and regulations from the Centers for Medicare and Medicaid Services (CMS) and/or state Medicaid programs.

But that is changing.

The emergence of a viral pandemic and social movements such as “Black Lives Matter” have further defined and exacerbated the disparities that prevent people from participating in the basic activities required to successfully address health problems, such as getting to an appointment, filling prescriptions, and consistently sticking to medications, treatments, and care plans.

The State of SDOH Today

The CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic) Care Act provided health plans with the much-needed flexibility to cover services for persons living with complex care needs. This coverage comes with the need to evaluate and ensure quality and value. At a member level, such services make an immediate difference and can be qualitatively evaluated and justified, which is often reflected in “member success stories” or anecdotal accounts from a provider or case manager. Health plans also quantitatively define success by citing numbers of referrals to community agencies, rides to and from the provider, meals delivered, etc.

This is incredibly important for demonstrating the operational success and scale of SDOH activities, but alone, these metrics will fall short of defining the relationship and significance between the intervention and outcome of interest, which is needed to calculate return on investment (ROI). Scaling SDOH efforts without truly understanding what works or doesn’t work (on many levels) can torpedo efforts, and most importantly, impact population outcomes.

Figuring Out Where to Start

Knowing how to begin or continue SDOH efforts can be overwhelming. It is a highly complex systemic issue that is woven into every aspect of our communities. The solutions aren’t always straight forward and determining the return or value of an investment in SDOH is difficult.

Fortunately, it’s not necessary to start from scratch or limit ourselves to what other health plans have done. There are many population-level SDOH success stories from which we can learn.

For example, the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program and grantees have thirty years of experience in this field, and their success could be leveraged by a health plan. The Ryan White CARE Act, enacted in 1990 to improve availability and access to care for low-income, uninsured, and underinsured persons living with HIV/AIDS and their families, recognized early on the importance of addressing SDOH. Adherence to appointments and medications, as well as partnering with community-based organizations to access resources, was directly linked to critical outcomes such as decreasing viral load, improving CD4 counts, avoiding unnecessary Emergency Department (ED) visits and hospitalizations, and improved management of common behavioral health issues such as depression and anxiety. This approach was fundamental to decreasing transmission and making HIV the manageable chronic disease it is today.

Leveraging effective evidence-based population approaches and interventions can speed up SDOH outcome achievement, translating to the ROI needed to sustain efforts over time.

Requirements for a Successful SDOH Strategy

Given the current state of SDOH, and drawing from extensive experience in this category, we know that the key to health plan SDOH strategic success lies in the following:

• In-depth, local understanding of what the members want and need to improve access, adherence, safety, and other factors that contribute to SDOH challenges (for example, the avoidance of an ED visit or hospital stay).
• The use of analytics to proactively identify hot spots, rather than reliance on incoming member calls, screenings, or blast communications.
• Developing programs in concert with a rigorous evaluation methodology to determine ROI.
• Identification of key performance indicators to continuously monitor what works and what doesn’t.
• Meaningful linkages, including value-based models, with community-based organizations to ensure access to high quality, sustainable, and scalable interventions.
• Compliance with CMS guidelines and audit readiness.

Final Thoughts on SDOH Strategy

Keep in mind that SDOH strategy shouldn’t stand alone, simply consist of delegated vendor activities, or try to address multiple issues at once. The overarching strategy should be led and championed at the highest levels of the organization through a mandate to align and integrate activities systemically with important areas such as member/health plan services, utilization management, network, quality, compliance, and analytics, among others.

SDOH strategizing is specialized and requires expertise in SDOH program design, implementation, operations, and rigorous program evaluation with underserved, vulnerable, and hard-to-reach populations in rural and urban communities; but it also requires expert knowledge of how health plans and the healthcare delivery system work. If you need help harnessing SDOH data, developing a strategy to address SDOH, or measuring the success of your SDOH initiatives, contact Kate Rollins at krollins@ghgadvisors.com.