Social Determinants of Health Considerations for CMOs

Regulatory compliance and payer contracts are related to screening and addressing SDOH, according to Kraft.

“Increasingly, we are seeing payers and regulators require screening for health-related social needs,” Kraft says. “We can predict that soon there is going to be a requirement that you were able to meet your patients’ identified health-related social needs. There are contracts that require that this work be done.”

Addressing SDOH is also linked to the well-being of healthcare providers, Kraft explains.

“It is distressing professionally to have a patient before you and you cannot address the needs that are impacting their health,” Kraft says. “Understanding social care needs and putting systems in place to respond to those needs will decrease the moral depression and moral injury that occurs for frontline staff.”

Screening for SDOH

Screening for health-related social needs is the first step to addressing SDOH.

In 2019, Highmark and its health system, Allegheny Health Network (AHN), developed an evidence-based SDOH assessment tool for the payer’s members and the health system’s patients.

“We leveraged clinically validated screening questions to create a 13-question assessment covering social needs across several domains,” Abebe says. “Through this assessment, we screen patients to identify their needs, then help to make connections to address these challenges.”

There are several ways for AHN patients to complete the SDOH assessment, according to Abebe.

“The SDOH assessment may be completed through our AHN MyChart app before a visit, on a tablet in the waiting room, or a one-on-one interaction during an appointment,” Abebe says. “We find that some patients enjoy the opportunity to complete the assessment on their own digitally, while others may not utilize technology the same way and may feel more at ease with someone asking them the questions.”

At Dartmouth Health’s outpatient clinics, which conducted 108,000 SDOH screens last year, patients complete the assessment tool through the health system’s patient portal before an appointment or through a tablet when they come to a clinic.

“Patients’ responses are secure, private, and voluntary,” Kraft says.

In the inpatient setting at Dartmouth Health, SDOH screening is conducted by nurses or care managers.

“The care managers see patients to help organize care and understand whether there are needs that need to be met before the patient is discharged,” Kraft says.

Addressing SDOH

Highmark and AHN use a community-support platform powered by findhelp to connect patients with community resources.

“The platform has a database of community-based organizations with resources that patients and members can access for free or at a reduced cost,” Abebe says. “They can access resources such as food, housing, transportation, and utility assistance.”

In addition, AHN has Healthy Food Centers and food prescription programs at six of the health system’s 14 hospitals.

“A doctor can write a food script for the patient, and the patient can take the script to one of our Healthy Food Centers and access healthy food and additional resources to support both their food insecurity needs as well as their chronic condition needs,” Abebe says.

“Patients who have had a positive health outcome as it relates to our prescription food program include a drop in A1C of 1.28%, an average drop in body mass index of 2.04%, and an average drop in cholesterol of 44.7%,” Abebe says.

In the inpatient setting at Dartmouth Health, care managers assist patients with making connections to resources in the communities where they live after they are discharged from the hospital.

“A resource that is used often is called 211, which is a centralized social care resource in New Hampshire,” Kraft says.

In the outpatient setting at Dartmouth Health, such as primary care clinics, the health system employs community health workers and resource specialists to work with patients who have health-related social needs.

“They offer to meet with the patients to provide assistance with social needs,” Kraft says. “They will meet with the patient, ask clarifying questions about the patient’s social needs, then help patients identify goals, set goals, and meet those goals.”

The community health workers and resource specialists try to equip patients with the skills necessary to address health-related social needs.

“The goal is to help patients meet their needs but not necessarily to do it for them,” Kraft says. “We coach patients and help them learn problem-solving skills.”

These community health workers are having an impact.

“In our most recent report, where we provided information on how well we did in 2024, we found that for community health workers that were working with patients and started an action plan to meet social needs, about 72% were completed,” Kraft says.