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Leverage digital to identify, relay, and address social determinants of health


Partner Perspectives
What is this?



Zip code, not just genetic code, is a significant driver of health outcomes.* Indeed, the environmental, social, cultural, community, economic, and educational influences on people’s health over time-collectively known as the social determinants of health (SDOH)-variably impact people's ability to lead healthy lives over time. Organizations have invested heavily in solutions such as affordable housing, case management, and food delivery services to attempt to address SDOH in recent years. However, many of these same organizations have been unsuccessful in mitigating SDOH due to factors such as poor patient follow-up, lack of necessary data to monitor interventions, and the expense and staffing challenges of in-person or telephone-based case workers.

Significant hurdles organizations continue to face include identifying barriers to care as they arise, creating workflows for resolving these barriers, and establishing a mechanism for ongoing monitoring to ensure interventions to address these barriers take place.

Digital health management provides a clear path forward for your organization to address these historically challenging hurdles. We recommend your organization follow these three steps to optimize your digital health management strategy to better identify and address the SDOH among your patient population:


Step 1

Engage patients digitally to identify barriers to care

To uncover SDOH affecting your patients, establish a digital channel for patient engagement. Care teams often struggle to reach, engage, and enroll underserved populations in care management through traditional telephonic outreach, since many patients don’t have a home phone, may frequently change addresses, and often don’t answer calls during business hours. But with a digital health management platform, your organization can capture day-to-day information on patient needs and behaviors you wouldn’t have access to otherwise-and in a way that is convenient for the patient.

To most thoroughly engage patients and uncover social determinants, introduce personalized education and use communication channels like secure messaging, texting, or video chat. These communication channels allow you to communicate with the patient as they go about their day, which makes it easier to uncover issues in real-time. In turn, this helps patients and caregivers build a more sustained and trusting relationship over time. In contrast to the low response rates often seen via traditional patient survey approaches, by building these long-term relationships with patients, patients become more likely to provide ongoing survey feedback and continue to communicate with their care team to provide vital, actionable SDOH data.

It’s highly rewarding to increase patients’ engagement, but your organization’s digital platform must also have an efficient and effective way of relaying, aggregating, and making sense of the valuable insights and data gathered to care teams.

Step 2

Leverage a digital platform that relays social determinants to the care team

Utilize a digital health platform to convey social determinants that are discovered to care teams. As described in step one, a digital health platform can build a human relationship that exposes nuanced insights, generates unique and valuable data, and creates more frequent touchpoints.

But how can you leverage technology to get this information in front of the right people at the right time? A digitally enabled workflow can surface these insights, while helping care teams find the signal in the noise.

A digitally-enabled platform enables your organization to:

• Receive real-time updates through a dashboard when a patient sends a message or answers a survey in a way that indicates the presence of barriers to care
• Filter through the data being collected and only alert the team when a response indicates a barrier, helping the team work efficiently rather than needing to evaluate every survey response
• Quickly send a follow-up message from the care team to the patient to further assess or address these barriers

A digital platform will help your organization to better interact with and understand patients in ways that were previously unachievable. But your digital management solution should also be able to connect the right resources to the patients who need them based on the patient data collected.

Step 3

Triage the patient to the right resources through a digital platform

The final step in addressing social determinants is addressing the patients’ needs by triaging the patient to the right benefit or resource. Today, organizations are investing in new partnerships as well as new staff members and resources to address a broader range of patient needs. But these resources are often underutilized, as patients aren’t connected to or even aware of them in the first place.

As the first point of contact with the patient, care teams need a method for triaging patient needs and connecting them to the right services-from specific organizational programs and resources to specialized staff, such as social workers, behavioral health specialists, dieticians, or pharmacists.

By connecting these resources on a digital health platform, the care team is able to utilize streamlined digital workflows to get the right resource involved for any identified barriers to care, as well as easily follow up with each staff member to confirm the patient’s barriers to care were addressed. The care team can also provide ongoing follow-up and support to the patient to make sure they have the health guidance and resources they need.

Consider the following example: a member of your care team receives a message from a patient using a digital health management solution indicating the patient has not picked up their medication because they don’t have a ride to the pharmacy. In this case, the care team member has been made aware, in real-time, that not only has the patient not taken their medication, but also that they are unable to get to the pharmacy. The care team member is now able to easily tag a social worker or transportation partner in real time via the digital health management solution to assist the patient in picking up their medication. Afterward, the care team member can send the patient a message to confirm the intervention took place.

An effective digital health management solution is the clear path forward

Though organizations are attempting to address SDOH from a variety of angles, most don’t have an effective way to actually connect patients to the right resources at the right time. An effective digital health management strategy will identify social determinants in real time, relay these barriers to care teams, and then facilitate the allocation of resources to address the barrier.


*Nature Genetics, "Genome-wide association analyses of risk tolerance and risky behaviors in over 1 million individuals identify hundreds of loci and shared genetic influences." January 14, 2019.

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