Social Determinants of Health: Closing the Gap

Addressing social determinants of health (SDOH) and ensuring health equity is a critical element to improving the health of a population; health equity and population health are interdependent. The health and wellness of a group or community made up of individuals is dependent upon the ability of those individuals to receive care. But annual wellness visits or screenings are unrealistic for many people who face barriers to access, such as lack of transportation, the inability to take time off of work, or the appropriate education and information to help them make an informed decision.   

Many people face barriers to healthcare because of where they live, their race or ethnicity, their education level, and many other factors. In fact, a person’s ZIP code is often more important than their genetic code, with only 10 to 20% of an individual’s overall health stemming from the clinical care they receive, while as much as 40 to 50% can be attributed to social and economic factors. However, using digital health technology, like GetWell Docent, which layers a human, empathetic component on top of digital communication, can be an important first step addressing SDOH and to ensuring health equity. 

What are social determinants of health?

What are SDOH? According to Healthy People 2030, SDOH are defined as the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, which are shaped by the distribution of money, power, and resources. 

While many conditions and situations make up SDOH, Healthy People 2030 groups them into five areas: 

  • Economic stability
  • Education access and quality
  • Healthcare access and quality
  • Neighborhood and built environment
  • Social and community context 

Examples include:

  • Safe housing, transportation, and neighborhoods
  • Racism, discrimination, and violence
  • Education, job opportunities, and income
  • Access to nutritious foods and physical activity opportunities
  • Polluted air and water
  • Language and literacy skills

Whether delivering care to individuals or taking a population health approach, healthcare organizations and health plans must consider the SDOH of the community they serve. To ensure you are providing whole-person care, you must take SDOH like unsafe housing, insufficient access to healthy foods, and opportunities for physical activity into account to understand what people need to be healthy. 

Navigating health — and the healthcare system — through digital and human touch points

But systemic public health concerns like the issue of food deserts — geographic areas where access to affordable, healthy food options is restricted or nonexistent — cannot be solved by a single healthcare provider or even by a single hospital or health system alone. 

As more organizations shift to a value-based care payment model — one where physicians are paid for the outcome of their care and not just the amount of care they provide — physicians who seek to address SDOH and discuss behaviors and social factors that impact health outcomes will be better positioned to make meaningful improvements in population health.

This is where technology can help. Digitally screening for SDOH and then navigating people through their healthcare needs can help improve the healthcare experience for individuals, scale care management teams, and better the overall health of your patient population. 

One way to do this is through social needs screeners — a practice recommended by many leading organizations, including the American Academy of Family Physicians. These screeners can help identify the specific non-clinical needs of an individual, such as  housing, food, transportation, utilities, and personal safety.

GetWell Docent leverages SDOH screeners to help identify such needs, and when concerns around various SDOH are surfaced, navigators — people who live and work with patients in a community — can guide patients through the complex health system. They direct people to community resources, preparing them and educating them on health topics, helping to mitigate health disparities. 

The benefits of combining digital and human patient navigation are three-fold:

Build and maintain lifelong relationships: Through digital engagement like AI-texting and other digital tools, organizations can longitudinally engage people across a population. Digital engagement leveraging personalized messages can encourage people to actively participate in their care and enable organizations to screen for health risks, collect SDOH, close care gaps, and foster loyalty.

Digitally navigate people through high-cost health episodes: Digital navigation helps reduce the response burden for providers and other care management teams.

Scale existing care teams: With resources tight, digital navigation and SDOH assessment helps organizations prioritize and coordinate messages within existing workflows. Care navigators — who typically are not clinical staff — can help guide people to clinical teams and the preferred digital or human services when and where it is warranted.

Bottom line

Persistent gaps in care impact people all over this country — and all over the world. People face barriers to care of all kinds. Income, education, geographical residence, ethnicity, race, gender, sexual orientation, age, and disability are just some of the factors that result in health inequities. 

Health disparities significantly impact care and cost approximately $93 billion in excess medical care and $42 billion in lost productivity per year in the United States. Addressing SDOH through both digital navigation and human guides can effectively help organizations deliver personalized care while also improving the care of the populations they serve.