Understanding Social Determinants of Health

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Tune into our first episode of the Avalere Health Essential Voice: Social Determinants of Health (SDOH) series. In this segment, Avalere experts from the Center for Healthcare Transformation and the Health Plans and Providers practice set the stage for how stakeholders are defining SDOH and the impacts of SDOH on health outcomes, specifically when addressing social risks and needs.
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“We are learning that addressing social risk factors is critical to implementing effective treatment plans, minimizing overall healthcare spending, and ensuring adherence to treatment plans.” Natascha Dixon-Edelin


Christina Badaracco , Research Scientist II, Evidence & Strategy

Christina Badaracco advises clients on quality landscape developments, healthcare quality improvement, performance measurement, and supplemental benefits.

Natascha Dixon Edelin , Principal, Associate Immersion Program

Natascha Dixon Edelin partners with clients to navigate dynamic market changes, understand their strategic opportunities and implement innovative payment and delivery models.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.


Christina: Hello and welcome to Avalere’s first episode in our Social Determinants of Health (SDOH) podcast series focused on understanding the SDOH. My name is Christina Badaracco and I am a Research Scientist and a registered dietitian in the Center for Healthcare Transformation here at Avalere. I am joined today by my colleague, Natascha Dixon Edelin, who is an Associate Principal in our Health Plans and Providers practice. In today’s episode, we will set the stage for how stakeholders are defining SDOH and how these factors impact their work.

As the healthcare environment transitions from volume- to value-based care, providers and other stakeholders are investing in strategies that will lead to improved quality of care and reduced overall healthcare costs. One critical area of focus is to address SDOH and social needs. Researchers, public health experts, and community organizations have sought to address these needs for many years. But only in recent years have healthcare leaders begun investing in, implementing, and even evaluating such initiatives to better understand the direct impacts on health outcomes and costs of care. But there is still wide variety in the ways these terms are defined. Natascha, can you start by defining some common terms, such as “SDOH,” “social risk factors,” and “social needs” for our audience?

Natascha: Absolutely. “SDOH” has become a buzzword in the healthcare industry. Yet, many have difficulty defining and describing how it can impact health outcomes and potentially support day to day processes for beneficiaries or patients. It is important to use common terminology, so let us start with defining SDOH. There are multiple frameworks to consider, but we will focus on the Healthy People 2020 framework, which was created by the US Department of Health and Human Services. They define SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” This is very similar to the definition used by the World Health Organization. While SDOH are often framed negatively, they are not inherently good or bad. Thinking of them as a spectrum where on one end they afford health benefits and on the other end they can cause harm. Building on that, the Healthy People 2020 framework characterizes five domains of SDOH:

  1. Economic Stability
  2. Education
  3. Health and Health Care
  4. Neighborhood and Built Environment
  5. Social and Community Context

These all address the underlying systematic issues that impact health outcomes. You can think of them as the root causes that contribute to health outcomes. Typically, when people are thinking of SDOH, they are thinking of social risk factors and social needs. Social risk factors address the social conditions associated with poor health outcomes. We can break each of the 5 domains of SDOH into specific risk factors. For example, if we take economic stability, we can break it into the following risk factors:

  1. Poverty
  2. Employment
  3. Housing instability
  4. Food insecurity

Each of which contains a myriad of unmet social needs, which will be specific to the individual level. If we look at housing instability risk factors, the varying unmet social needs could include: someone who is homeless and does not have housing; someone with housing who does not have utilities; or someone who has housing and is suffering from domestic abuse. Again, all are issues related to housing instability but require individual and specific social needs. What is important to also note is that these terms are used interchangeably. When looking to effect change, it is important to be very clearly aligned on whether you and your group are looking to address:

  • underlying systemic issues at a macro level; or
  • risk and social needs at the individual level.

Christina: Great! Thank you, Natascha. While public health departments and community-based organizations offer many programs across the country to improve these conditions and behaviors, initiatives within the healthcare system and pharma tend to be more limited and disparate. Why should entities within traditional healthcare settings be interested in these programs and investing more in them?

Natascha: Only a small percentage of health outcomes are determined within the clinical environment. Over 80% of health outcomes are determined by social and economic factors, health behaviors, and physical environment—in other words, outside of clinical environment. Typically, in healthcare when we apply a siloed approach to meeting SDOH. Clinicians are responsible for clinical outcomes, and social workers and community-based organizations are responsible for filling social risks and needs. However, we are learning that addressing social risk factors are critical to implementing effective treatment plans, minimize overall healthcare spending, and ensuring adherence to treatment plans.  You know Christina, you and I both attended the SDOH RISE conference and they had an amazing panel of customers – others would call them patients or beneficiaries – who discussed the social risks and needs impacting their families. I was really struck by the number of individuals who had jobs, were able to maintain those jobs through the COVID-19 pandemic, and yet were required to assess whether they were going to put food on the table or their medication; or whether they were going to pay for their medication or their children’s medication. Again, you got to see first-hand the impact of social risks and needs on health outcomes. Finally, COVID-19 has really highlighted the health inequities within the United States (US). We have seen firsthand the impacts of social risks and needs on treatment and recovery. One area that does not get discussed often is the impact of housing instability on COVID-19 recovery. So, what do you do with patients who no longer need emergency care, need to be isolated but they do not have a home to go to. Where do you send them? We will talk more about this, but again this goes back to addressing the specific social risks and needs to ensure effective recovery. As we are learning about how social risks and needs impact health outcomes, we begin to see health plans, health systems, providers, and pharmaceutical companies all taking on greater responsibility to solve for social risks and needs.

So, Christina, I am going to turn the tables a little. As a dietitian, you have researched and written about the impact of food scarcity and insecurity on health outcomes. Can you share with us how food insecurity impacts an individual’s health outcomes?

Christina: Sure, Natascha. The Healthy People 2020 goals that you referenced earlier define food insecurity as the disruption of food intake or eating patterns because of lack of money and other resources. Lack of access to healthy food in a consistent manner can lead to malnutrition, which can manifest in different ways. In much of the rest of the world, this can be a matter of undernutrition, which might be visibly apparent because stunted growth, muscle wasting, reduced immunity, etc. But in the US, and much of the developed world, more often food insecurity may lead people to rely on processed, calorie-dense foods that lead to overnutrition, which similarly increases risks of many different chronic diseases like obesity or diabetes. People with limited income may need to decide between paying for family’s groceries and medical bills. They may also live in areas without reliable or safe access to healthy food or face many other barriers to this important social need. In particularly, amidst the current COVID-19 pandemic, we know that the rate of food insecurity is growing, and the related conditions to malnutrition and chronic disease are more likely to make people susceptible to contracting and suffer from the virus. And this makes it of greater concerns to all the stakeholders we have been talking about today.

Natascha: Great, thank you!

Christina: Natascha, can you offer a few examples of how healthcare stakeholders across the country are attempting to address SDOH?

Natascha: Yes! One example people may be more familiar with is patients lacking transportation to their provider’s office or the hospital. We see health plans partnering with Uber and Lyft to provide transportation so patients can have access to those services. A second example is health plans and pharmaceutical companies looking at the social risk factors and needs impacting medication adherence. Some of the solutions they are providing are instructions in multiple languages and providing audio instructions. If transportation is an issue, medication may be sent to the home.

When I was working with another organization, I had the pleasure of being able to go on a home visit with a community-based worker and she specifically visited home-bound, high-risk patients. One of the key aspects of her job was ensuring medication adherence. You can imagine that if you are high-risk and on multiple medications, understanding how to take those and when to take those is not easy. However, we are seeing these various areas of healthcare becoming very creative in addressing those unmet social needs.

As a last example, there are the impacts of housing instability on COVID-19 recovery. If you think back to the height of the pandemic in Newark, New Jersey, emergency rooms were full and at a premium. And yet, you had individuals occupying those beds and no longer needing emergency care but needed to remain isolated. The problem with discharging them was that many were either:

  1. Homeless, in which case did not have a home to go to. And at the time shelters were not accepting individuals who were COVID-19 positive patients; or
  2. Had a home but could not self-isolate

So, hospitals were not sure where to discharge them but needed the beds for the high acuity patients coming in. Within the New Jersey Department of Health, they organized this cross-disciplinary team that turned a hotel into an alternative recovery center, supporting these individuals with a safe recovery option. We are seeing folks across the industry coming up with innovative ways to address social needs and risks that positively impact patients’ health outcomes.

Christina: What a great example. Thank you for sharing, Natascha! How do stakeholders know which SDOH are impacting their communities, beneficiaries, or clients? And how can they track and evaluate their interventions to understand the impact?

Natascha: Data can come from multiple outlets when evaluating SDOH, such as electronic health records (EHR) data, medical claims, zip code or county-level data, screening tools and surveys, and other social data, etc. What can pose a challenge is integrating all disparate data sets to understand their total impact. What is extremely important when assessing SDOH is the granularity of the data you are assessing. Many folks when evaluating SDOH data are looking at the 5-digit zip code, which will give 42,000 distinct groups. On the other hand, at Avalere we use a national SDOH database that evaluates at the 9-digit zip code data level, which allows us to look at 30 million neighborhoods. You may be asking, why is this important? This is important because if you take a zip code in New York City, you will see significantly varying socioeconomic status. You will have a whole host of SDOH that impact on either end of the spectrum positively or negatively. And things can get a bit muddy. But when you can look at 30 million separate neighborhoods, you can hone in on which SDOH are impacting which members.

To your second question, once you have that data what you can do with it, we have used the data to look not just at medication adherence but compliance in general. We can look at which individuals are more likely to be non-compliant when it comes to vaccinations, mammography screenings, and cancer screenings to give health plans or community-based organizations an opportunity to intervene. We have also evaluated risk factors to predict member disenrollment to health plans.

And finally, we have used SDOH data to help health plans inform and define their member engagement strategies. With one health plan we used data to assess their dual-eligible  population – which are individuals who qualify for Medicare and Medicaid, identifying a second group of non-dual-eligible members who did not qualify for Medicaid with very low incomes and had the same clinical outcomes. This is important because the second group did not qualify for Medicaid and they did not have access to the same level of services. Having this information allowed the health plan to determine how they would want to intervene and drive better health outcomes. Using a variety of data can a help pinpoint key risk factors impacting your population to create the most appropriate intervention strategy.

Christina: Thank you Natascha. I agree, and it sounds like collecting those data and being able to analyze them is important for these stakeholders to ensuring beneficiaries needs are met. So, what else can the audience do to learn more about these issues and what Avalere and leading stakeholders throughout healthcare are doing to address them?

Natascha: First we recommend that listeners go to www.avalere.com and search for “SDOH” to see previous articles we have written about this topic and analyses with various types of data. Please also stay tuned for other upcoming podcasts that will dive deeper into this topic and understanding the role of the manufacturer, health plans, and other stakeholders. We also continue to share information about our projects in this area at conferences, such as AHIP and AcademyHealth. You can also reach out to myself or my colleagues directly with questions.

Christina:  Thank you, Natascha, for that information and thank you for joining us today. Your insights are invaluable to the listeners. Thank you all for tuning in to Avalere Health Essential Voice. Please stay tuned for more episodes in our SDOH series. If you would like to learn more, please visit us at our website.




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