Close this search box.

Eight Ways to Optimize Patient Engagement to Address Social Determinants of Health


Pinpointing and addressing social determinants of health (SDOH) is a growing concern for both payers and providers—identifying those factors can help optimize the health of the member/patient base and ultimately change lives. Awareness of and outreach for social determinants are especially important for managed Medicaid plans and provider networks, Medicare and Medicare Advantage plans, and all types of risk-based healthcare providers.

The impact of SDOH on patient health and outcomes is widely known, and solving for social determinants of health can also affect financial bottom lines. Studies show addressing the factors and removing obstacles to care can result in a 30% per person reduction in overall healthcare costs.

In addition, advancing health equity and tackling health disparities—critical missions in healthcare today—require stakeholder collaboration for identifying and solving for SDOH. Even before the pandemic, social determinants were having a major impact on health outcomes—especially for the most vulnerable populations. Consider:

  • There is a direct link between the likelihood of smoking and lower income.
  • Stress related to disparities has a direct link to health.
  • Chronic exposure to social and environmental stressors often results in biological “wear-and-tear” that places individuals at higher health risk.
  • Lack of transportation, health literacy, employment, childcare and internet influence care access.

Most SDOH efforts begin by collecting actionable, risk-factor data that can illuminate the stumbling blocks and inform intervention efforts. That data may come from self-reporting, claims, census or enrollment databases. Psychographics, health status information, patient behavior and demographics—including ZIP code—should all play a role. Predictive analytics can then be used to find potential high-risk consumers who need a little extra help.

Some of the key areas of focus we’re seeing in the industry right now include:

  • Health literacy
  • Healthy food availability
  • Secure and safe housing
  • Employment
  • Transportation
  • Healthcare access and connectivity

Let’s take a look at how specific patient engagement-related strategies can help your healthcare organization up its SDOH intelligence and stay in touch with consumers to recognize needs effectively and efficiently.

Communicate early and often. A multi-step and multi-channel engagement strategy can help uncover SDOH issues and work to solve for them over time. More frequent healthcare consumer engagement—from live phone calls and interactive voice response (IVR) to email and text messaging—is a great way to nurture connection and build trust with health plan members and patients. The more comfortable they feel as early in your relationship as possible, the more receptive they may be to your help.

Make the most of health risk assessment outreach. Health information and assessment outreach can be a vital first step in establishing rapport and fostering transparency and accountability. Carenet Health data has shown that human-anchored health risk assessments deliver more powerful needs identification versus passive digital surveying methods alone. When connected with trained engagement specialists, or in some cases registered nurses, individuals respond more openly to one-on-one interaction. Through conversational probing and motivational interviewing methods, an outreach team can explain the impact of lifestyle issues, communicate the availability of valuable resources and help with next steps. (See a case study on this topic here.) If non-live engagement tactics are used, keep in mind that long surveys are an instant barrier to gaining the information you need, as are complex questions.

Show seniors some extra TLC. Tackling social determinants of health in seniors often starts with personal outreach in the form of one-on-one check-ins. From assisting older consumers in navigating benefits eligibility and enrollment to approaching sensitive topics such as anxiety and depression, a little care and concern for their well-being can go far. Formalizing your senior outreach plans and implementing them strategically is also key.

Lean into telehealth as a touchpoint. Engagement via telehealth utilization is often an overlooked SDOH strategy. In addition to eliminating transportation and childcare barriers, 24/7 telehealth connections (via care coordinators, registered nurses and online physician consults) can explore obstacles and discuss situations that might be impacting a person’s health. Their need for on-demand care can be a useful jumping-off point to larger needs discussions.

Prepare for language barriers. Communication is great, but if it’s not in a language that’s understood, it’s worthless. Plan for multi-lingual translators and translations as needed for your populations.

Make SDOH a post-discharge priority. After a patient is discharged from a hospital or care facility, reviewing and addressing social determinants of health can help prevent ED visits and impatient readmissions. It sounds like a logical and necessary step, but it’s one that often goes unheeded by both health plans and providers. Does the person have a strong social network, access to healthy food and a plan for medication management? Asking questions about their lifestyle and resources, and offering solutions within their reach can be a huge step in promoting positive health outcomes and keeping costs low for all.

Continually tweak the SDOH conversation. When initiating consumer engagement regarding SDOH, ensure your team members and/or healthcare engagement vendor are going above and beyond to garner open, honest responses and gently encourage solutions. Discuss why preventative care is so important. Employ proven activation tactics. Optimize your scripts with strategic testing and analysis. Supplement patient SDOH screening with additional data sources and community resources.

Integrate data and technology systems. Addressing SDOH requires personalization for heightened individual relevance, and that requires data. Plus, effective leveraging of data requires data integration. To make SDOH a priority, connections between systems also need to be a priority, whether it’s working in the electronic health record or patient portal, or tapping care coordination platforms or digital transportation marketplaces. Once you’ve captured data on health determinants, be sure to utilize that insight for better risk segmentation, targeted scripting and versioned calls to action.

Follow up, then follow up again. Providing information on how to get assistance isn’t enough to truly solve for SDOH. Helping individuals with follow-through is just as essential. A patient or plan member with substantial social and healthcare needs may not have the ability or resources to move forward after a referral, especially if they encounter any impediments. Health navigation advocates can help patients and health plan members move through the often-confusing networks of available social and healthcare services, which can vary by individual, region, insurance and state.

These are just a few ideas to fuel your SDOH strategies and planning. To learn about other ways healthcare consumer engagement can address and help solve urgent challenges such as SDOH needs, download our white paper, The Value of One-on-One Engagement in Addressing Healthcare’s Top Concerns, or contact us to learn more about Carenet Health’s engagement work.