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To Proactively Address SDOH, the ‘Top of Funnel’ is Critical


We can identify and engage the right people. But to make a real difference in any community, a managed care organization, government agency or healthcare system needs to have a robust list/dataset of its population so the tools, processes and individuals that come after can do the work to identify and engage members with the highest needs.

The need to address social determinants of health (SDOH) has reached a pivotal moment. In healthcare, we are acutely aware of the unequal distribution of healthcare and the imbalanced risks for certain populations. We are heading toward an uncertain economic future. This moment we find ourselves in demonstrates the significant need to not only prioritize SDOH but also to rethink and redesign how we address them.



Imagine the impact we could make if we proactively provided social care, rather than waiting for patients to present at the emergency department with SDOH-based needs or acute health issues.

That’s simpler said than done, of course, but if we leveraged the vast data we have at our fingertips to identify individuals and populations at highest risk of social needs, we could intervene with community health navigators (CHNs) and other resources before those needs present as acute health events.

To be effective, the following are important:

Community engagement. Medical professionals need to find ways to partner with other organizations to augment their current SDOH models of care and fill gaps that have been identified.

Tech-enabled and data-driven efforts. A proactive, omnichannel model with outreach, engagement tools, education and follow up can guide patients down a better path to improved health and social outcomes.

We recently ran a proactive social care pilot with a managed care organization (MCO) in the Midwest. One of the things we found was that, in order to kick off a successful social care program, the ‘funnel’ is really important. We can identify and engage the right people. But to make a real difference in any community, an MCO, government agency or healthcare system needs to have a robust list/dataset of its population so the tools, processes and individuals that come after can do the work to identify and engage members with the highest needs.

Filling the funnel

Despite all the new and innovative technology we have available today, when running data-driven campaigns, it often still comes down to the numbers. The more we have, the better chance of reaching — and engaging — a measurable number of individuals that can benefit from additional resources and support.

To get started, it’s important to have a “home base” where all the data can be stored, mined and managed. That tool should integrate with others, such as electronic health records (EHRs), in order to bring data from multiple sources into one. Once you have a place to house the data, you can work with local and regional organizations — community-based organizations, faith-based organizations, at-risk providers and others addressing SDOH — to compile a working dataset of at-risk individuals and populations within that community.

As the list grows and proactive outreach efforts are underway, you can begin to identify patterns that help further home in on areas or groups where SDOH needs are the greatest, and therefore engagement rates are likely to be higher.

Engaging at-risk individuals

Finding the right individuals — those with needs who are open to additional support — is the first hurdle to any proactive program. After all, with nearly all systems in the U.S. set up to help people reactively, there can be a feeling of swimming upstream. That’s why one of the biggest keys to engagement success is establishing trust early with all individuals, not only by using local and community-based care navigators but also by making sure they are actively out in — and engaging with — the community.

A few interesting findings from our work in the Midwest:

  • Individuals with too many or too few SDOH needs tend to have lower overall engagement rates.
  • “Warm” transfer from screening to intake improves engagement and retention; any lag time between screening and intake can negatively impact outcomes.
  • Direct incentives — for example. a gas card — improves engagement.
  • Having access to an interpreter did not improve engagement.
  • Referrals have a much higher rate of engagement and retention.

When it comes to incentives, we found that it was more about building trust between the CHN and individual, and less about the incentive itself, demonstrating how critical trust is to driving any measurable impact.

Based on those findings, we recommend the following engagement practices (in addition to others):

  • Have CHNs available in the evening – between 5:00-9:00 – to offer more flexibility around clients’ work schedules.
  • Identify a few CHNs who can have an “open” schedule in order to receive warm transfers.
  • Design and integrate SMS/text-based engagement strategies.
  • Implement automated reminders before scheduled calls.
  • Offer and expand incentive programs.

There is a lot of work to be done if we want to shift the way we address SDOH from a reactive to proactive model. It won’t happen overnight, but these are some tangible steps we can take to start laying a path that leads not only to lower costs, but improved outcomes and a more equitable health system for all Americans.

Ted Quinn is CEO and founder of Activate Care.

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