By Dr. Joe Nicholson

Although the long-term economic impacts of COVID-19 remain unclear, the ramifications will probably outlast the public health crisis and be felt for years to come. This is especially true for socioeconomically disadvantaged populations, including racial and ethnic minorities, for which the crisis has been particularly hard. Not only are these groups more likely to get sick and die from COVID-19, they are also more likely to lose their jobs or see their wages cut as a result of the crisis. And even though employment is rising and household budget constraints have eased in recent months, the employment rate remains below pre-pandemic levels, and millions of households still report experiencing challenges with food insecurity, housing insecurity, and transportation issues.

What does this economic uncertainty mean for people’s health?
There is an undeniable link between a patient’s health and several socioeconomic and environmental factors—also known as social determinants of health (SDOH). Conditions like an unsafe home environment, food insecurity, homelessness, and limited access to health care can impact a staggering 50 percent of patient outcomes. In fact, SDOH can affect outcomes just as much as patient behaviors (mental health, diet, and physical activity) and the clinical care an individual receives.

It is not surprising that concerns about money, transportation, food, and housing prevent people from concentrating on their health. However, when those fears are coupled with a lack of access to care, the roadblocks get even bigger. And when there is a massive public health crisis like COVID-19, it shines a spotlight on the almost insurmountable difficulties certain populations face in receiving urgent and specialized care—and what the ramifications of those hurdles are.

Essentially, the pandemic has widened the gap between the "haves" and the "have-nots," and the people who struggled with SDOH factors before the pandemic are struggling more now, and without support, they will continue to struggle going forward, even as other populations move beyond the crisis and regain their economic footing.

Health care organizations have an obligation to step up
Providing the best possible care is part of almost every health care organization’s mission. Yet, if we downplay, overlook, or disregard the role of SDOH in improving the health of our patients, we not only fall short of our mission, but we do our patients a disservice. Even though we cannot entirely fix the psychosocial and environmental factors that exist today, we can recognize their impact and try to make a difference in the lives of those we serve. Although this may seem daunting—and in many ways it is—there are some fundamental things we can and should be doing now.


1. Using data to identify those at risk. Before health care organizations can start to address SDOH, they must first identify which of their patients are having trouble. Hospitals, physician practices, and other providers collect myriad data about patients, as do their health partners, including payers and pharmacies. Within this data, there are some key indicators that could point to SDOH concerns. For example, if patients are not filling or refilling their prescriptions regularly, there may be medication adherence issues fueled by a lack of transportation or financial barriers. Similarly, frequent appointment cancellations or a lack of scheduled follow-up visits may indicate a problem. With advancing data analytics capabilities, organizations have the opportunity to use predictive algorithms to calculate the likelihood that someone is facing SDOH challenges and could be a good candidate for intervention.

Although algorithms exist today, the opportunity for advancement in this area is significant. Current options rely mostly on provider and payer data, but to be more effective and accurate, the algorithms will need to incorporate nontraditional data as well, such as that from public databases, community-based organizations, wearables, and more.

2. Supplementing data-driven identification with point-of-care identification. Predictive analytics is not the only identification strategy that works. There are less technology-dependent options that can still make a difference. For example, we collaborated with a Texas-based provider organization to create a process whereby physicians can refer patients who may need assistance to a team of Health Advocates. This team, which includes social workers and nurses, contacts patients to discuss their needs and then connects them to the right resources, making a clear difference in the community.

3. Connect with patients in meaningful ways. Once an organization has an idea of who may be at risk, it can start reaching out to patients to gather more details about what help they need. Not everyone has the same SDOH concerns, so solutions must be individualized to meet unique patient requirements. Having a supportive framework in place that includes care coordinators, social workers, dieticians, and nurses can enable an efficient, consistent, and compassionate outreach process. By using a questionnaire that team members can use to assess a patient’s current circumstances, organizations can ensure they are capturing the relevant information and creating a true picture of the patient’s situation. One such tool is the PRAPARE assessment. PRAPARE stands for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. It is specifically designed to help providers collect actionable SDOH data.


Although many SDOH programs rely on phone calls to touch base with patients, restricting outreach to one communication channel may limit the ability to engage with people, especially those that do not have access to the chosen channel. Before using different modalities, organizations should think through the HIPAA implications and make sure they are engaging in private and secure conversations. While this represents an extra step in the connection process, the benefits of reaching patients in ways that are most comfortable for them makes the extra effort worthwhile.

4. Leveraging all available resources. The pandemic forced many health care organizations to think outside the box in how they deliver care. And as an industry, we can apply some of those approaches to SDOH going forward. For example, telehealth has been a game changer in connecting with patients who need care but who must remain socially distanced. Organizations should consider offering this option for people who have transportation or other SDOH barriers that prevent them from visiting the doctor in person. While entities may run into challenges with telehealth in areas where Internet connections are spotty, the technology can be an effective pathway that links individuals with care in areas where Internet access is available and pervasive.

Community-based organizations (CBOs), such as food banks, drug treatment centers, and shelters, are also critical resources, and health care entities should be building relationships with these groups, so they understand what is available in the community and how to match patients with relevant programs. Health plans also provide a number of programs, and organizations should become familiar with what different plans offer and who qualifies for those programs. Making these connections can take time and resources. But, by having an administrative infrastructure that supports the work, organizations can ensure their SDOH programs stay current with available resources.

It is going to take focus and commitment
There is no one-size-fits-all solution for SDOH, and we may never fully fix the problems we face. However, health care organizations can make meaningful progress by embracing the above mentioned strategies and committing to continuously evolving their SDOH programs. The key is remaining vigilant and open to new ideas and collaborations as we learn more about COVID-19’s impacts and what they mean for at-risk populations. By seizing emerging opportunities to overcome socioeconomic and environmental barriers, we can help those we serve achieve more consistently positive health outcomes over the long term.


About the author: Dr. Joe Nicholson is the chief medical officer at CareAllies, providing strategic direction, business development expertise, and clinical oversight.