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Why Community Health Workers Are Vital to Addressing SDoH


Tackling SDoH issues requires efforts beyond traditional healthcare roles.

Taking medical history

What do 79-year-old Carl who has diabetes and dementia, 83-year-old Lucille who is wheelchair bound and suffers from CHF, and 92-year-old Marisol, a non-English immigrant who is terminally ill have in common? While all three are elderly and have serious chronic health diagnoses, managing their care is made much more complicated and costly because of the impact of social determinants of health (SDoH) in their lives.

Specifically, Carl lives in a rundown trailer with his wife with no electricity, running water and lacks access to healthy food. Lucille has no access to affordable transportation to doctor appointments and social activities. Marrisol’s family does not understand what hospice does and feels like they would be abandoning her if they didn’t provide her care personally.

Their circumstances offer insights into some of the most common SDoH: lack of adequate housing, access to healthy food, and transportation, as well as healthcare illiteracy.

Health plans recognize the impact of addressing SDoH

While most healthcare executives have long recognized the impact that SDoH play in the health of members, until recently most of them didn’t fully embrace the integration of SDoH in their overall approach to member care.

That’s rapidly changing.

A number of state Medicaid programs now include a requirement that Medicaid managed care plans address these critical needs for their members. A recent study determined that SDoH had an 80% impact on a person’s health outcome vs. only 20% for clinical care.

And, while addressing the SDoH in members’ lives can result in a significant improvement in health outcomes, it also has a dramatic impact on their cost-of-care.

The key to a successful approach

What should a successful approach for a health plan managing SDoH include? The basics include tools for collecting key member information, identifying resources that would address SDoH, merging SDoH, member HRAs and clinical records, and the capability to identify the highest risk members in the plan.

Related article: 4 Ways Health Plans and Communities Can Address SDOH

But most importantly, a plan should have feet on the ground to engage with the member in person. These community health workers can provide the “secret sauce” for a health plan to integrate traditional care management with contemporary approaches to addressing SDoH.

Community health workers make a difference

Community health workers are trained and certified lay staff with specialized skills who work and live in the communities where the health plan members live.

It was a community health worker who visited Carl and his wife numerous times to convince them to move to a place that could provide proper care and a healthy diet for him.

It was a community health worker who was able to help Lucille learn how to use her health plan transportation benefit, which allowed her to more easily make doctor visits and have much more freedom in her life.

And, it was a community health worker who understood the cultural concerns that Marrisol’s family had about hospice care would violate their personal involvement with her care.

For Carl, Lucille, and Marisol, their health plan’s understanding of the role that SDoH played in their care helped them more than any clinical intervention could have. As difficult as each of their circumstances were, they were all improved by the services provided by their community health worker as part of their health plan’s approach to the SDoH impacting their lives.

Melinda Henderson, MD, CMD, FAAHPM, is chief medical officer at PopHealthCare.

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