How organizations are prioritizing SDOH to improve whole-person health

As a healthcare organization, you recognize the significance of addressing social determinants of health (SDOH) to enhance the overall wellbeing of your patients or members. Social determinants such as economic stability, education access, neighborhood environment, social context, and healthcare quality significantly impact health outcomes and disparities.

Research shows that individuals facing challenges in these domains are more susceptible to chronic conditions and mental health issues, underlining the need for a multifaceted approach to addressing SDOH and improving whole-person health. Numerous studies suggest that SDOH account for between 30-55% of health outcomes and have a greater impact on population health than the healthcare industry.

How hybrid care can bridge SDOH gaps and help enhance whole-person health

Hybrid care presents a transformative approach that integrates in-person, virtual, and digital care to provide continuous and personalized healthcare support.

In the context of SDOH, hybrid care models offer a unique opportunity to strengthen whole-person health by addressing physical and mental health needs, as well as the social and environmental factors influencing long-term clinical outcomes.

Here are three ways hybrid care can enhance whole-person health within your SDOH strategy:

1. Integrate physical and behavioral healthcare

Physical and mental health are intrinsically connected and are of higher prevalence among underserved populations and lower-income individuals. Stress, anxiety, and depression can increase the likelihood of someone having one or more chronic conditions, which can, in turn, create or exacerbate mental health issues. And alternatively, chronic conditions can trigger those and other mental health issues and symptoms.
 

Addressing physical and mental health in one setting can better address and coordinate whole-person health needs, reduce costs, and improve overall care quality and outcomes. Integrating mental health into primary care environments alleviates stigma and other access barriers by normalizing mental health as a routine part of healthcare, making it less likely for people to face discrimination or judgment when seeking help. Plus, it’s cost-effective and clinically useful to align primary care with behavioral health experts, who can work closely together to manage care, monitor progress, and address needs before they become more serious.

How can you integrate by organization type?

• Payers should consider using a virtual primary care program to refer members to a virtual therapist or psychiatrist or to a digital behavioral health program for between-visit support.
• Providers should explore integrated care models that use virtual and digital care tools and a remote psychiatric provider network to expand behavioral healthcare into primary care clinics.

2. Deliver more comprehensive, condition-specific support

By leveraging virtual and digital care, your organization can provide easy access to continuous, affordable support. This is especially valuable for those with one or multiple chronic conditions, ongoing mental health concerns, or other persistent care needs. Your organizations can provide more comprehensive support through:

• Referrals to in-network virtual specialists or therapists, who provide more in-depth expertise for chronic conditions or mental health concerns.
• Patient enrollment into digital companions or specialty care programs, which provide additional support, guidance, and education for conditions such as diabetes, musculoskeletal pain, hypertension, pregnancy, anxiety, or depression.

This tight coordination of specialty care helps individuals with more complex health needs to more easily navigate their care and access clinical experts in a unified, convenient, and consumer-centric environment.

3. Identify and close gaps in care

With virtual visits, providers can see an individual in their home environment and review any potential SDOH needs or care gaps first-hand.

For example, if someone with hypertension is working to manage their condition with medications and lifestyle changes but isn’t seeing any improvement, the provider could ask to review their regular drinks, snacks, and meals during a visit. Taking a closer look at ingredients and flagging high sodium in certain foods starts the conversation around a more heart-healthy diet. This allows the provider and care team to address SDOH gaps like health literacy, economic stability, and access to healthy foods and connect the patient with more affordable, nutritious food options and resources to better manage their condition.

Providers can address and close care gaps during virtual visits, improving health outcomes. Digital companion programs can also flag and help close gaps in care and non-medical SDOH needs for these populations through ongoing, chat-based conversations, reminders, and escalations as needed.
 

Northwell Health, New York’s largest healthcare provider, has seen the benefits of virtual companions in its maternity services department. The provider combines in-person care with a chat-based digital companion program to address maternal mortality rates. Through the program, Northwell Health determined that 16% of routine pregnancies were medium-to-high risk and quickly escalated care to address those risks. The provider was able to flag physical and mental health risks and rapidly intervene, improving patient and pregnancy outcomes.

Read our full eBook to learn more about the results of Northwell Health program, as well as how hybrid care can strengthen your whole-person care and SDOH strategies.