blocks showing factors in health
by Bill Miller

Imagine you are leaving the hospital after an extended illness or a severe injury. You are set to receive follow-up care from a home health care nurse. You have a list of medications that you will need to pick up at the local pharmacy. Your path to recovery seems well-established. But after a week, you’re back in the hospital.

What happened?

For many Americans, this is unfortunately an all-too-common situation. Perhaps a lack of transportation means there’s no way to get your prescription, and so your fever spikes. Or you can’t afford follow-up care, so you cancel your appointments, which leads to an infected wound. Those non-medical factors, known as social determinants of health, play a significant role in a person’s overall health and well-being. In fact, clinical care impacts only 20% of a patient’s health. That leaves 80% affected by social determinants.

“Whole-person care” is a bit of a buzzword these days, but more and more, providers and payers are beginning to recognize the importance of ensuring that all of a patient’s needs are met—and that goes beyond just the physical ones.

The catch? It’s easier said than done.

Increasing Focus on Social Determinants of Health
Social determinants of health are becoming integral to effective care. The health care industry is slowly getting on board with this, which we can see in the increase in value-based purchasing agreements, the expansion of supplemental benefits in Medicare Advantage plans (such as food and transportation services and general living support), and the popularity of health care and community care partnerships. There are two main factors at play:

>>The Economic Impact: Delivering health care is expensive. That’s why so many stakeholders are invested in the success of value-based care, a reimbursement model in which payments are based on the quality of care provided, rather than the quantity of services provided. The Centers for Medicare & Medicaid Services (CMS) is aiming to have half of Medicaid and commercial contracts on value-based plans by 2025. Because value-based care focuses on performance, addressing social determinants can help providers better understand and manage that performance.

>>The Potential for Improved Health Outcomes: Addressing social determinants of health at both the patient and population levels reduces health disparities and improves health outcomes. Many studies have validated this, including a December 2022 case study involving Reading Hospital, a 714-bed acute care hospital in Berks County, Pennsylvania. Reading Hospital used a $4.5 million grant from CMS to implement the Accountable Health Communities model and assess whether addressing the social needs of local Medicare and Medicaid beneficiaries impacted total health care costs and inpatient and outpatient health care utilization. What they found was nothing short of astonishing: By alleviating food insecurity in their community, emergency department utilization, hospital readmissions, and—yes—health care costs all decreased by 30% or more.

The Role of Technology
Today’s providers are being held accountable for reaching population health goals while trying to reduce costs. So it’s critical that they have the right tools to identify the socioeconomic drivers of poor outcomes and higher costs and the strategies to combat them. That’s where technology comes in.

First, by connecting the continuum: It’s estimated that up to $265 billion worth of care services for Medicare fee-for-service and Medicare Advantage beneficiaries could shift from traditional facilities to the home by 2025. When more care is delivered outside of a hospital setting, where there is round-the-clock monitoring and staffing, it’s essential that we use technology to facilitate coordination and communication among providers. Traditionally, medical and non-medical caregiving has been fragmented. Closed-loop referral systems can power collaboration between health care providers and social services providers to ensure patients get the services they need and that all members of the care team are kept informed about a patient’s overall well-being. Patient engagement tools can also play a role here by giving patients themselves the ability to share their needs and
to communicate directly with their caregivers.

Then, equipped with data on the social determinants of health, providers can define and document the increasing complexity of their patients and transform care with integrated services and community partnerships to help meet the needs of their patients. That will go a long way to address the health equity issues plaguing our nation.

Assessment tools that capture social determinants of health data in a consistent and structured way will help providers better serve their patients by considering non-medical issues that may be affecting their health; facilitate better outcomes by connecting patients to community service providers to address specific needs; build closer relationships with payers, other health care providers and community-based organizations; and ultimately increase funding and reimbursement by enabling the ability to participate in value-based care.

Whole-person care and acknowledging the increasing importance of social determinants of health are becoming top priorities for payers and providers. These are essential to improving patient outcomes and reducing high health care costs. Fortunately, it’s becoming easier to connect clinical care with social care to address social determinants of health through the use of smart technology that can help us achieve lasting outcomes.

Technology can be used to make sure no patients slip through the cracks by opening the lines of communication and connecting providers across the continuum. We’re also starting to make the data work for providers, using it to identify where health inequities exist and how we can help facilitate specific interventions to address and to measure the impact of those interventions.

There’s still a long way to go. But I’m confident we can make huge strides in health equity in the coming years and close the gaps that are hurting millions of Americans.

The time is now. Let’s get to work.

Bill Miller is CEO of the health care technology firm WellSky. Learn more at