Clinical Insights

The Case for Social Determinants of Health and In-Home Health Assessments

Written By
Marisa Smith

As many readers are undoubtedly aware, the factors in which a person is born, grows, lives, works and ages are believed to determine 40% of their health outcomes1. Numerous studies more than point to it, and yet, member populations can be represented without accounting for Social Determinants of Health (SDOH). This is especially important for low-income members who are at higher risk of developing chronic conditions.

The Right Time and Place


In the fifteen minutes PCPs are afforded with patients—the ones who actually show up for scheduled office visits—there is arguably never going to be time to acquire the full spectrum of SDOH data. Though patients can generally be expected to communicate their ailments, it’s within reason for them not to cover every aspect of their home and personal life during an exam. For many reasons, patients may avoid diving into how long it’s been since they were visited by a family member or lamenting how difficult it was to get to the doctor’s office.

It’s worth mentioning that social isolation has been described as a comparable risk factor to that of high blood pressure or how transportation services have been shown to reduce patient absenteeism for non-emergency medical visits3. At every level, from the World Health Organization down to individual providers, the impact of SDOH is being loudly supported, but members miss this message when the proper attention isn’t possible. High-risk members trend toward overutilization as undocumented and unattended SDOH continue to influence their health outcomes unchecked.

Finding the Time


Bridging the divide between known and unknown is complicated, but mapping it doesn’t need to be. By segmenting members with gaps in care and meeting them where they live, the data that would have been lost is documented in a way that wasn’t possible with a conventional visit. A one-hour In-home Health Assessment can record general health and cover more determinants than CMS’s survey—the AHC Health-Related Social Needs screening tool. Key SDOH data on literacy, transportation, lifestyle, social services utilization, nutrition, connectivity, cognition and more are asked directly of patients, with time carefully devoted to document the answers.

Further assessments of a member’s environment such as fall risks, fire hazards, medication storage, or even family dynamics are, to say the least, highly unlikely to note accurately within any office or hospital visit. Standardizing the collection of this information in a routine in-home assessment assists in creating a meaningful profile for each member visited. These visits—as they are targeted campaigns—document trends for patients with shared conditions and environmental risk factors. The data being recorded provides common denominators that inform interventions and initiatives such as duals identification and enrollment.

Dual Eligibility


A compelling benefit of collecting and reviewing SDOH is the possibility to identify members who are dual eligible (duals). It’s been reported that national spending associated with the care of duals makes up about 33% of Medicaid spending and 34% of Medicare spending, though their actual enrollment numbers only represent 15% and 20% respectively4. The disproportionate cost of care—as many will suspect already—is due to the elevated rates of chronic illness and/or long-term care needs among this subset of Medicaid/Medicare enrollees.

Pinpointing members within your covered population who are dual eligible and not enrolled can be the missing key to better health outcomes and substantially reducing the cost of care. CMS has announced they are further opening the door to greater supplemental benefits. This is great for Medicare Advantage organizations with the infrastructure in place to better utilize data that’s been collected. However, CMS’ openness to new supplemental benefits is still underwhelming for mid-sized and smaller plans with fewer resources to track patient environmental data, coordinate with community-based organizations (CBOs), and persuade CMS that additional benefits being utilized led to measurable improvements in health outcomes. That being said, precedents are being established by plans who are high performing while maintaining a significant population of dual-eligible high-utilizing members.

Plans are seeing success with intervention programs that incorporate meal assistance, transportation, housing stabilization and other varied aspects of SDOH. And though the programs being explored are as diverse as the members being cared for, the first steps are not. Universally, effective interventions have and will continue to begin with risk assessments. Meeting members more than half-way and beginning the process of cataloging their circumstances is the proven way to record, track, and manage their health outcomes.

There is no way to perfectly predict how well an intervention will perform, but there is currently a great deal of encouragement—read as “pressure”—for CMS to accept a broader spectrum of evidence. If that door is to open further, it will be after the continued push of plans and providers who have proven there are ways to address SDOH, coordinate care across silos, and demonstrate value all the while. For now, the only known paths are being cleared through in-home health assessments, illuminated by the insights found in each successful visit.








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