Social Determinants of Health

As population health management and value-based contracting evolves, organizations across the care continuum are taking a more holistic approach to how health care is delivered, with a keen eye on improving health outcomes and cost savings. 

With that, there is an industry-wide recognition that social, economic, environmental and societal factors have a profound impact on the delivery of care, particularly for Medicaid populations.

These social determinants of health (SDoH) can all lead to a direct decline in a patient’s overall physical and mental health. That is, if a patient suffers from alcohol or substance abuse, can’t understand medication instructions, has food security or housing problems, or simply doesn’t have transportation to the doctor’s office, even the best-laid care plans are sometimes doomed to fail.

HealthEC, which has pioneered the integration of SDoH and health care technology, uses embedded SDoH assessments for patients on our CareConnect platform – allowing care coordinators to address health care barriers and prevent them from interfering with individualized care plans.


By creating holistic plans that integrate SDoH assessments, the prospects for better patient outcomes rise significantly.

  • Integrate community based providers into care management programs
  • Mental health
  • Meals on wheels
  • Soup kitchens/food banks
  • Church groups
  • Transportation services
  • Assignable tasks to all providers
  • Stratification with SDoH co-morbidities (conditions)
  • SDoH impact on utilization, cost and outcomes

Executing the SDoH Strategy

Consumer-Level Data Model

  • Demographic and socio-economic variables
  • Ethnicity and language variables
  • Consumer residential profiling variables
  • Household unit profiling variables
  • Lifestyle and engagement group variables

Analytic and Predictive Processes

  • Integrating member data
  • Calculating LCM metrics
  • Segmenting target populations
  • Profiling relevant segments
  • Conducting predictive analysis
  • Estimating the prevelance of health conditions
  • Estimating demand for services

Assessment Sample





Results-Based Approaches to Priorities:

  • Life circumstance intelligence metrics
  • Predictive risk, predictive cost, resources utilization
  • High or rising cost patient
  • High cost diagnosis or cost per patient
  • High ER users and non emergent use of ER
  • Frequently admitted patients or admissions for low acuity
  • Re-admissions by facility, diagnosis
  • Focus on chronic care or annual wellness
  • HCC risk adjustment factor maximization strategy
  • Medication adherence rates
  • Quality score improvement

Combat the Rising Number of Opioid-Related Deaths with a Risk Stratified Approach

From identifying at-risk patients to the doctors and pharmacies that prescribe and dispense the most, see how HealthEC’s Opioid Analytics Module is using data to tackle the opioid epidemic head on. For a deeper dive into opioid analytics, download our datasheet now.

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Additional Reading


HealthEC's Dr. Sanjay Seth on Social Determinants of Health

Media: HealthcareNOW Radio

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Social Determinants and the Impact on Risk Stratification and Care Delivery

Media: HealthEC Blog

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Social Determinants of Health and the $1.7 trillion opportunity to slash spending

Media: Healthcare IT News

Read More >