As health plans seek ways to reduce healthcare costs and increase the quality of care, it has become increasingly evident that addressing social determinants of health (SDOH) is essential. Identifying and addressing SDOH must be a fundamental part of an integrated care management program as physical outcomes will not improve unless individuals’ social, behavioral, and environmental health needs are met. Now more than ever, plans must understand SDOH within the populations they serve. 

In this article, we’ll cover:

• What are social determinants of health (SDOH) and why are they important?
• Why SDOH is a critical part of a holistic, integrated care approach
• New standards and state mandates that incentivize SDOH screening
• How technology can help incorporate SDOH support into care management 

What Are Social Determinants of Health and Why Are They Important?

Social determinants of health (SDOH) refer to the myriad of social and economic variables that impact an individual’s health. Examples of SDOH include inadequate access to safe and affordable housing, clean water and food, and overall proximity to poverty. SDOH fall into five categories:

• Economic Stability
• Education Access and Quality
• Health Care Access and Quality
• Neighborhood and Built Environment
• Social and Community Context

Screening for SDOH provides health plans with a more holistic and comprehensive understanding of an individual’s health and well-being. A siloed approach, in which SDOH, physical health, and behavioral health are addressed separately, fails to accurately or effectively support members. 

According to significant research, SDOH impact well-being:

• 70% of health outcomes are attributable to social and environmental factors, which patients face outside of medical care.
• Stress caused by SDOH, such as poverty, can negatively affect health across a person’s lifespan
• SDOH can impact family health across generations 

Why Integrating Both SDOH and Behavioral Health Is Critical

SDOH directly impact an individual’s behavioral health. Recent studies show that economic and social variables, as described above, contribute to several mental health issues:

• Poor housing or lacking of housing is predictive of depression and anxiety.
• Poor diet increases the risk of mental health issues and even the development of psychiatric disorders. 
• Adults living in poverty are at a higher risk of adverse health effects from obesity, smoking, substance use, and chronic stress.

Integrating not only behavioral health in care management, but also SDOH will enable health plans to provide more equitable and effective support to their members. For example, in addition to screening members with chronic conditions for behavioral health needs, care managers should screen for SDOH. An underlying barrier to a member’s improved health may be an inability to make important appointments due to transportation issues. Health plans

cannot address the root cause of health issues without understanding underlying social factors.

New SDOH Standards and State Mandates for Health Care Organizations 

Several factors are accelerating SDOH screening and support in the U.S., particularly among Medicaid and Medicare populations who are often more impacted by SDOH. New healthcare standards and mandates have emerged that incentivize health care organizations to address SDOH.

For example, new HEDIS measures in 2022 (Social Need Screening and Intervention (SNS-E) encourages health plans to assess and address the socioeconomic environment of individuals including access to transportation, food, and housing.

States have also begun to incentivize—financially and non-financially— Medicaid Managed Care Plans to address SDOH.  Some states, too, incorporate MCOs’ performance in addressing SDOH measures. 

Finally, research shows an increased urgency for SDOH screening and support in health plans post-pandemic, heightening the need for an integrated approach to care management.

How to Integrate SDOH into Holistic Care Management

Integrating physical and behavioral health as well as SDOH support is the backbone of a holistic healthcare delivery strategy—one that appropriately and accurately addresses some of the most fundamental causes of health issues. Technology can help health plans efficiently and effectively support members by improving identification of physical, behavioral, and SDOH needs at scale and appropriately respond to them.

Whether a health plan is already delivering whole-person care management or not, incorporating SDOH screening and support through innovative technology is a natural addition.

NeuroFlow: The Future of Integrated Care Management

Built to simplify the key elements of an effective SDOH program (screening, risk stratification, intervention, and resource delivery) NeuroFlow provides the necessary infrastructure needed to serve large populations at scale:

Screening

NeuroFlow’s digital, remote screening of populations—alongside standard Behavioral Health screenings—deliver assessments like the Health Leads questionnaire.

Risk Stratification

With population-wide screening and stratification, health plans can assess population needs more accurately in order to deliver more efficient and effective care management. 

Intervention and Resource Delivery

By leveraging referral networks and connecting at-risk individuals to local community resources, care teams can immediately send individuals the resources they need to find affordable housing, food, or transportation in their communities. 

Health plans can utilize NeuroFlow’s Response Services team, a team of certified crisis professionals, to perform this outreach, particularly for high-risk individuals, and connect members to appropriate resources.

NeuroFlow is an end-to-end technology solution helping health plans to identify SDOH, deploy appropriate resources, and make informed decisions about care. With next-generation capabilities, localized resource delivery, and comprehensive data for care teams, NeuroFlow’s SDOH solutions turn critical data into life changing action. 

To learn how your organization can provide integrated care management that supports your members’ whole health using NeuroFlow, click here.

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