Addressing Social Determinants of Health with Technology During Public Health Emergencies

Addressing Social Determinants of Health with Technology During Public Health Emergencies

By Joe Nicholson, DO

It’s estimated that 40 percent of American families struggle to meet at least one of their basic needs, such as food, housing, transportation, or healthcare. That was before the COVID-19 public health emergency began earlier this year, which has since amplified socioeconomic inequities across the nation. Those at heightened risk face dire consequences, whereas more affluent groups have the resources to buffer the impact an emergency might portend.

With COVID-19, even individuals with regular access to food, transportation, and housing are being thrust into troubling situations after losing their jobs or experiencing a cut in pay and/or hours. In fact, 33.5 million Americans have lost their jobs to the coronavirus as of late April. Many more are unable to self-isolate to avoid exposure to the virus due to their work conditions or housing insecurity.

With so many Americans affected by the pandemic, implementing social determinants of health (SDOH) outreach programs across the care continuum is pivotal.

Implementing a SDOH program, or further building out an existing one, can lead to improved health outcomes for patient populations that are struggling. Health systems and other practices can focus their technology and available infrastructure to help at-risk populations stay safe, healthy, and connected to their community services by focusing on these key factors:

Strengthen SDOH Outreach Within At-Risk Patient Populations

By looking at fresh ways to focus their technology and available infrastructure, independent practice associations (IPAs), health systems, and other providers can deepen their existing SDOH outreach by implementing the necessary changes that address the most vulnerable populations. Focusing resources to help at-risk populations stay safe, healthy, and connected to community services both during this pandemic and in its aftermath can go a long way to improving overall SDOH outcomes within a community.

Identifying those individuals in need of a safety net and connecting them to resources to minimize the impact of the existing social disparities are key to ensuring the needs of at-risk populations are being properly addressed. Increasingly, health systems are using electronic health record (EHR) data, consumer data, and other health data to predictively model and score patient populations, uncovering SDOH risk in ways that were previously unachievable.

Developing the right approach may require a review of existing operating models, where the health system will need to evaluate which workflows, operating procedures, and technology capabilities can be put to use to screen, identify, prioritize, connect, and support their patients with SDOH needs.

The Role of Telehealth

Telemedicine can provide an effective means to conduct appointments and check on at-risk individuals, while keeping them safe in their homes and limiting their risk of exposure. With the rapid spread of coronavirus, telemedicine has received significant attention and support across the regulatory, reimbursement, and provider communities, with many practices quickly implementing newly reimbursable telehealth options quite quickly.

These video conferencing appointments are taking place using a variety of methods—including traditional telehealth apps, FaceTime, and Zoom.

Interestingly, since telehealth appointments also reduce the drive time needed for face-to-face interactions, they also create new opportunities for practices to maximize the patient volume that can be achieved via audio-visual (A/V) visits, when possible, and audio-only when an A/V option is unavailable.

Still, success with telehealth requires a certain technology literacy from patients.

“While virtual healthcare has gained a tremendous push recently, we’re finding telemedicine literacy is a challenge,” said William Torkildsen, MD, chairman at South-Texas-based independent physician association Valley Organized Physicians (VOP). “We estimate only 40 percent of our Medicare patients are virtually fluent.”

To meet patients’ needs, practices may need to consider partnerships that help put easy-to-use technology into patients’ hands. “We need a simple option for virtual patient visits and monitoring. Something that’s preprogrammed, user friendly, and easily readable with large fonts, where all the patient has to do is turn it on and keep it charged,” Torkildsen said.

Regardless, telehealth capabilities improve outreach and convenience, while helping maintain appropriate COVID-19 physical isolation recommendations for patients and clinicians alike.

The Power of Data

SDOH programs can also use available electronic health record (EHR) data to identify and prioritize potentially at-risk patients. An increased emphasis on data tracking and reporting can help identify the patient populations that may need additional support for their SDOH needs.

For example, using data from the EHR, VOP and CareAllies Community Health Advocate Team (CHAT) piloted a series of wellness check-in calls, reaching out to patients identified as high risk. With this program, a team of social workers and licensed vocational nurses (LVNs) directly reached out to patients to identify, address, and help resolve SDOH needs by educating, assessing, documenting, referring, and assisting with resource fulfillment.

In 2019, using data analyzed from practices’ records, the team identified approximately 733 unique SDOH barriers for 486 unique customers and worked to resolve more than 400 of those. The outreach helped pinpoint the need for community services such as utilities or food access, additional in-home assistance and transportation, among others.

Applying a similar method of outreach doesn’t need to be complicated. Practices may consider developing a “frail-elderly index,” using EHR and other available data to identify and reach out to patients with a history of falls, multiple comorbidities, malnutrition, or medication compliance issues—a sign that they may be choosing between their medication and food. Once you have identified patients who are at risk for a social disparity gap, the goal is to connect with them (e.g., at-risk elderly patients who may be isolated during this pandemic and unable to access the resources they need to stay healthy and maintain peace of mind).

“We’ve had physicians across our practices reach out to patients living alone during this time of social isolation, those who were identified as potentially being isolated and without support,” Torkildsen said. “We recorded those results and have been able to take action on the patient’s behalf, connecting them to necessary resources.”

Building Stronger Communities Begins with Strong Partnerships

The COVID-19 public health emergency is taxing our healthcare systems and community support networks like no other emergency before it. Ultimately, it will take a greater focus on community partnerships and collaborations across the care continuum to improve the ability to identify, assess, and prioritize those individuals whose health may be impacted by SDOH factors.

Organizations that can identify their unique services and how technology can help to support those services are on solid footing to help address these social inequalities and make an impact that can lead to improved health outcomes and a healthier community for all.


Joe Nicholson ( is a physician executive who provides strategic direction, operational oversight and thought leadership for CareAllies’ clinical programs and operations, including ACO and social determinants of health strategies and operations.