Author: Terri Steinberg, MD, MBA, FACP, FAMIA, Chief Medical Officer and Chief Strategy Officer, Medecision

Plans and providers know that attention to social determinants of health (SDOH) plays a key role in improving member outcomes, reducing costs and utilization, and advancing health equity and access. The ability to effectively identify SDOH barriers continues to be an elusive goal for many organizations, one that is reflected in cost and quality outcomes.

With timely information regarding SDOH factors, care teams can mitigate issues that are delaying and preventing members from receiving appropriate and necessary care. To be more effective, plans and providers need to identify SDOH risk factors earlier and connect members with resources sooner.

But that’s easier said than done … or is it?

The Right Technology Helps You Address SDOH Barriers

Recently, endeavors to address SDOH factors have improved considerably due to technological gains and breakthroughs that are making it easier than ever before to quickly address care barriers.

Specifically, the most innovative technology solutions are helping plans and providers:

  • Proactively identify SDOH barriers
  • More easily connect members to community resources
  • More effectively increase member engagement to ensure they engage with resources

Not all technology is created equal, however. While some solutions truly support the above results, others may make similar claims but do not follow through on their promises. Plans and providers know this all too well.

To learn more about how innovative organizations are proactively addressing SDOH, read Medecision’s latest report: A New Dawn for the Healthcare Industry’s SDOH Strategy

The Most Effective SDOH Solutions

To ensure your organization selects the best SDOH solution partner, this piece shares findings from a recent report by Leavitt Partners. The report, based on a comparison of eight SDOH solution technologies, identified the following common capabilities shared by the most effective solutions:

  1. A solution that identifies relevant SDOH data for members—instantly. Traditionally, plans and providers rely on claims data from previous encounters to identify SDOH risk factors. This data is at least 90 days old. Reports are often spotty, missing data, or, for many Medicaid members, nonexistent. The most effective SDOH technology solutions address these challenges head on. They proactively predict and identify SDOH barriers in real-time, based on data from multiple sources across the healthcare ecosystem.
  2. A solution that provides real-time SDOH alerts based on configurable rule criteria. The most effective SDOH solutions also enable users to configure alerts and profiles based on their own rules and digital touchpoints. For example, if the plan is focused on decreasing readmissions by ensuring recently discharged members attend follow-up appointments, it should be able to configure its rules to alert the care management team to members flagged for a transportation barrier so that transportation can be provided.
  3. A solution that features an always accessible, customizable, and up-to-date directory of community resources. Even when SDOH barriers are identified, many organizations struggle with lack of staff time and bandwidth to find and connect members with appropriate resources. To facilitate the process, the most effective SDOH solutions offer a curated, updated list of community resources that is easily accessible to the care team whenever they need it. The solution should also include an updated directory of national providers and the ability to customize and add established service providers, local or otherwise.
  4. A solution that includes SDOH referral initiation and tracking capabilities. While the community resources directory is key, it’s just the first step in crafting a more effective SDOH strategy. That’s why the most effective SDOH solutions enable plans and providers to track referrals end-to-end and close the loop, ensuring members actually connect with the resources and receive the support they need.
  5. A solution that can be tailored to your organization’s unique budget and needs. Every healthcare organization is different, as are the needs of every member population. As a result, the most effective SDOH solutions aren’t a one-size-fits-all approach. To meet the needs of diverse populations, these solutions are easily scalable and customizable to fit the organization’s budget and its community’s specific needs.
  6. A solution that delivers personalized outreach using a variety of channels rather than general, automated, pre-populated communications. An individual’s contact preferences can vary based on age, access to technology, and other factors such as housing and internet access. The most effective SDOH solutions enable plans to meet members where they are by communicating via their preferred channels (text, phone, email) and deliver communications that are personalized, and therefore more likely to be read.
  7. A solution that provides real-time dashboards that show trending data over time. The most effective SDOH solutions also make it possible to monitor the program’s impact over time, by tracking key data such as referral status, readmissions, overall costs and outcomes, and resource allocation. The biggest benefit? With these dashboards, organizations can quickly identify gaps and improvement opportunities.
  8. A solution that simplifies compliance with NCQA health equity accreditation mandates and CMS legislation. New regulations are increasing the pressure to accelerate efforts to remove SDOH barriers and enhance care coordination. The most effective solutions should support compliance, providing data related to NCQA health equity accreditation, Transitions of Care Act rules, and CMS prior authorization transparency regulations.

SDOH: By the Numbers

  • Outsized impact. Clinical care impacts only 20% of county-level variation in health outcomes, while SDOH affects as much as 50%.
  • Costly considerations. One study found that addressing patients’ social needs led to an 11% reduction in total healthcare costs.
  • Emergency avoidance. Patients living with mental health issues account for 1 in 8 ED visits. Connecting them to SDOH resources sooner could improve outcomes and reduce the number of costly ED visits.


With the right technology solution, plans and providers can equip their care teams with information to uncover SDOH barriers and proactively work to address them. This will help ensure a better healthcare experience and quality of life for, as well as reduce emergency room utilization, improve chronic disease management, and enhance the overall health and well-being of individuals and communities.

Medecision recently launched Aerial Social Care Coordinator, which features all the above capabilities, making it much easier for plans and providers to address SDOH barriers. We’d love to provide you with a short demo to help you learn more about how the solution could help your organization.

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