How SDOH Screening Tool Combines Clinical and SDOH Data To Deliver Quality Care


Social determinants of health, SDOH, can be defined as the economic and social factors that impact patient health. They play an integral role in defining the criteria for enhancing patient care.

Furthermore, while the medical fraternity recognises these factors’ importance which is well-recognised and acknowledged, a gap exists between recognising its impact and utilising it. Adding value care and treating the person is greater than refining the landscape and addressing the SDOH to improve health outcomes.

It highlights the need for a well-structured SDOH assessment to eliminate the barriers and increase patient care. This article elaborates on the need to overcome the obstacles to patient care. Keep reading.

Social and Economic Factors Play a Major Role in a Patient’s Overall Health

Among the many SDOH factors, social and economic factors play a significant role in the overall patient’s health. As per studies, these encompass 40% of factors that affect the health outcome. It is followed by health behavior covering 30%, clinical care 20% and physical environment adding 10%.

For example, an individual’s overall income, employment and social support play a significant role in determining a patient’s enhanced health capacity. In addition, community safety and social/ family support represent how healthy the patient is.

In simple words, understanding the policies and programs based on the health factors will assist in bettering the patient’s health outcomes. 

“SDOH, like essential availability of resources, transportation, healthcare knowledge and income level, determine 80% of overall patient health outcomes.”

Find out the  Impact of Social Determinants Of Health (SDOH) on COVID-19 here

How to Overcome SDOH Barriers to Patient Care

  1. Addressing SDOH: Who Is Responsible?

As per the Leavitt Partner Survey, although most healthcare professionals believe SDOH is integral for patients but rarely believe in addressing the responsibilities.

The survey includes findings of 621 physicians between June to July 2017. The survey highlighted:

  • 75% of physicians believed informing patients about health care insurance, pricing, and enrolling in plans would assist them.
  • 66% believed assisting patients by arranging transportation would aid them
  • 54% indicated increasing patient income
  • 48% highlighted providing affordable housing
  • 30% thought all the above factors are essential for patients

“However, the same survey also reported that the insurer, doctor or physician is responsible for assisting patients with finding transportation, food security or income”

The above survey addresses the need for broader societal investment in social services and public health. Herein, the onus lies in reducing the burden on physicians. It is necessary to channel the resources and commitment towards policies and programs that aid physicians in incorporating these practices.

2. Many of the Members Are Not Comfortable Providing Sensitive Information

One of the blocks is the members who are often reluctant to share details about their income, social status, employment, etc. It possesses a barrier in letting the providers gain a complete picture of their social status. Besides, members may not be completely upfront about revealing details surrounding their lifestyle that will assist providers in implementing plans to provide enhanced health services.

3. The Idea of Value-based Care and Treating the Person by Analyzing Social Determinants of Health Disparities

There is a growing need for SDOH assessment to provide value-based patient care. It focuses on analyzing which social determinant of health and health disparities impacts the patient and accordingly providing treatment that would guarantee enhanced patient care.

It offers a holistic approach to redefining the healthcare landscape by combining patient conditions with the treatment provided.

4. Overcoming SDOH Will Be a Continuous Effort

The need to overcome the SDOH is a continuous cycle not limited to the initial point of contact. These include providing accurate care management solutions and integrating analytics and engagement to enable payers to provide the patient’s support. Besides, it also highlights the need for effective communication, encouraging members to take efficient action.

These include:

  • Verifying the SDOH factors reported by patients
  • Notifying appointment reminders
  • Providing additional resources to fill the gap

Check out WHO guidelines on Social Determinants of Health here.

How Integrated Analytics of Social Determinants of Health Screening Tools Helps Payers and Providers Overcome the SDOH 

  1. SDOH Assessment Connecting High-risk Individuals and Communities With Critical Healthcare Resources

The medical field operates under a risk paradigm that focuses on implementing behavioral modification of high-risk individuals to prevent diseases. Social Determinants of Health (SDOH) data assess subgroups of the population highly exposed to risk factors for illnesses, including physiologic impacts and chronic stress.

The SDOH assessment further bifurcates patients into categories highlighting high-risk individuals and communities prone to critical healthcare risks. It will thereby enable providers to provide healthcare resources for enhancing patient health.

  1. SDOH Tool Combines Clinical and SDOH Data

SDOH tools work by integrating social determinants with clinical data. It, at this moment, assists providers in gaining a better understanding of the patient requirement and overall population needs. The tool combines data from key stakeholders, providers, payers, members, home healthcare workers, community-based support organizations, mental health providers, and government entities.

  • It assists providers in improvising their revenue cycle performance
  • It improves patient’s financial experience
  • It provides insights for the healthcare provider to focus on the economic situation faced by patients
  • It allows us to gain a complete spectrum of social risks to implement intervention strategies
  • It helps to improve treatment and adherence strategies and lower the total costs
  1. Lowering Healthcare Costs Through the Prevention of Chronic Conditions

Considering the SDOH factors advantages in saving the rising healthcare costs for chronic conditions. It helps to find how different factors can impact the patient’s health and thereby assist in preventing chronic conditions before it blooms into an illness.


SDOH screening helps bridge the gap between providers/ payers and the patients to provide enhanced health facilities. A 2020 study published in the JAMA Cardiology highlights the Machine Learning (ML) model employed for implementing SDOH data. The model was trained and developed to predict in-hospital mortality rates accurately and categorized patients into race-specific and race-agnostic communities.

This data helped improve the prediction of in-hospital mortality among patients with chronic heart conditions. The model utilized retrospective data from The Get With The Guidelines – Heart Failure registry to identify heart failure hospitalization spanning 12 months from 01 Jan 2020 to 31 Dec 2020.Equipo’sSDOH screening tool divides the determinants into six categories: neighborhood, lifestyle, health service, support, social and employment. This allows payers and providers to get accurate information about the patient’s condition, ease the overall process, and bridge the gap between patient care due to social determinants. Schedule a demo today to deliver the quality care by lowering the risk.