Why Tracking the Social Determinants of Health is Crucial to Value-Based Care

Did you know that the care delivered within the walls of a hospital or a doctors office accounts for only 10% of an individuals’ long term health outcomes?

Research suggests the other 90% depends on the social determinants of health (SDoH), factors that include where a patient is born, grows up, works, and lives. These factors may seem insignificant, but they effectively determine a persons’ health as well as the length and quality of their life.

SDoH play a critically important role in a person’s health, yet most American providers still receive the majority of their income via a fee-for-service (FFS) model.

The FFS model reimburses providers based on the number of patients seen and services provided. In other words, a doctors’ income depends on the number of services offered, not the quality.

Fortunately, this is starting to change. Since the passage of the Affordable Care Act (ACA) many providers are transitioning to value-based care (VBC). VBC focuses on providing quality health outcomes through the use of big data, analytics, and care coordination. However, to achieve these results, providers must partner with social workers and other community entities to facilitate communication and collaboration.

Learn how tracking SDoH and value-based care go hand-in-hand, why factors like food and housing impact healthcare outcomes, the challenges of connecting social services with providers, and how SDoH impact whole-person care.

Does tracking SDoH really provide better outcomes?

Compared to other developed nations, America’s traditional FFS healthcare model is generally more costly and produces negative outcomes. However, by considering SDoH like housing stability, access to food, and substance use disorders at the point of care, providers can take appropriate steps to reduce readmission rates, setbacks in treatment, and unnecessary expenses.

But how is this possible? The majority of patient data is housed in silos and currently, there’s little communication between providers and community organizations. Enter value-based contracts.

How can social services contribute to value-based care?

As providers make the switch to VBC, they’re also transitioning to value-based contracts with community provider networks. These provider networks are designed to positively impact healthcare when patients aren’t in the hospital or exam room.

This is important because many vulnerable patients– like the elderly, homeless, or those with substance use disorders– lack transportation and housing security. As a result, they’re less likely to attend their medical appointments or have the financial means to adhere to a treatment plan. Without access to adequate resources, health problems are more likely to get worse and cause adverse effects.

The skills that social workers possess directly align with value-based healthcare models. Social workers play an important role in improving people’s health through prevention, integrated care, and improving SDoH. They also build relationships with vulnerable individuals outside of the medical setting, similar to a nurse’s role in a hospital.

That’s not all, though. As providers transition to value-based contracts, they’re also using social workers as IT consultants on applications, tools, and programs that deliver better care for patients after they leave the hospital.

What are the pros of connecting value-based care with social services?

Connecting value-based care with social services presents a number of benefits. For example, a provider who has access to a patient’s SDoH information, physical health, and mental health records can identify potential risk-factors prior to meeting them in-person. This information can also be used to develop an individualized treatment plan and better coordinate care between specialists.

Integrating SDoH data and medical information also allows providers to take a more holistic approach to care. Under the FFS model, a doctor might rush through an appointment, offering impersonal service. With value-based care, providers can “break out of the box” and really get to know their patients.

What are the challenges of connecting value-based care with social services?

Many states set goals for connecting SDoH and healthcare, but the technology is still in its infancy. In addition, many state laws don’t clarify how managed care organizations can use flexibilities in federal law to address their patients’ unique socioeconomic needs.

These problems are exacerbated for behavioral health providers, who have more of an uphill battle. According to experts, there are far fewer opportunities for behavioral health providers to transition to VBC payment models because of poor integration between physical and behavioral health services. Thankfully, progress is being made to change that.


America’s transition to value-based healthcare is underway, but it’s a slow process. By developing comprehensive provider networks and coordinating care between social workers and doctors, Americans can achieve better health and improved quality of life.









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