Creating a Successful SDOH Strategy

Gartner reports that healthcare CIOs are ramping up efforts to create a social determinants of health (SDOH) strategy and implement capabilities, tools, and technology.

And, many healthcare organizations are launching different initiatives to identify, predict, and address SDOH like housing, transportation, literacy, and access to care.

Some organizations are integrating SDOH into their population health management programs, or, as the case with Kaiser Permanente, integrate SDOH capabilities into their EHR.

Social, behavioral, and environmental factors contribute to more than 70% of some cancers, 80% of heart disease, and 90% of stroke.

At the core of addressing social determinants of health are value-based care and the goal of treating the whole person rather than just their medical condition as a path to better outcomes and long-term lower cost.

Creating a successful SDOH strategy and system requires data, dashboards, and digital – screening, analytics, and integration with targeted community resources.

Start with Proper SDOH Screening

Only 62% of healthcare organizations are screening populations systematically or consistently.

Proper SDOH screening and data collection starts with using the right tools and integrating the screening process into regular patient/member interactions and engagement.

Standardized SDOH screening tools are available, but many healthcare organizations have not mainstreamed their use into care management, engagement, or care delivery workflows.

The University of California at San Francisco offers a helpful SDOH screening tools comparison that can help an organization identify the social needs categories that they want to focus on, including food, transportation, neighborhood/housing, education/literacy, financial, and community.

SDOH Data in Population Perspective

Successful population health management programs need the right data so that they can prioritize areas addressing social determinants of health, as well as determine those community resources they should include as part of their SDOH network.

States with a higher ratio of social-to-healthcare spending from 2000 to 2009 saw better patient outcomes.
Care Management Dashboard charts

As you decide what the most opportune times to collect SDOH information via screening are, the next step is to visualize the data in dashboards so that you can make population-based, as well as individual-based decisions.

By monitoring changes in responses over time, patterns will emerge that will guide your strategy for addressing social determinants of health. Plus, you can analyze patient/member health behaviors in light of their responses.

There are many resources on dashboard creation and use. We’ve created a best practices guide that highlights four healthcare client case studies to help you align your dashboard to your goals, realize useful insights, and make better decisions in addressing SDOH.

Success Through Community

20% increase in median social-to-health spending ratio resulted in 85K fewer adults with obesity.

Tighter collaboration, formal working agreements, as well as the integration of essential technologies can enable the local ecosystem of providers, healthcare organizations, and social/service resources.

Integrating with databases and intake processes with critical social and community resources is where the action takes place, and patients/members start to make positive changes.

This point in your SDOH strategy is where involving human-centered design experts can build a bridge among technology, healthcare, community, and people. They can gather global requirements, determine technical and user needs, as well as ensure that whatever technological connections are created are easy to use, adopt, and scale.

One pilot created an active integration between healthcare and social resources for Parkland’s Accountable Health Communities. Patients interface with Parkland, and their screening is shared through an electronic interface, enabling referrals to over 100 community-based organizations.

No matter the size of a healthcare organization, addressing SDOH to whatever degree is possible, will have an enormous impact on patient/member adherence, behavioral change, and quality of life and health. Data, technology, and connections to the community are vital in identifying, predicting, and addressing these needs for individuals and populations.

Need to strategize and plan a comprehensive approach to SDOH for your organization? SDLC Partners has extensive experience in all aspects, including strategy, analysis and dashboards, program development, and creating custom digital tools and interfaces.

Contact us to discuss your SDOH goals.


“Social Determinants of Health Analytics for Healthcare CIOs.” Gartner. August 30, 2019. ID G00439850.

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