SDOH: The Next Frontier? Part 1: Screening for Health Related Social Factors

Health is more than just a set of clinical metrics. There is an identified connection between key social determinants of health (SDOH), such as employment, housing, and transportation, and poor health. The World Health Organization (WHO) defines SDOHs as “the conditions in which people are born, grow, live, work and age.”[1] Research by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute states that social and economic factors make up almost 40% of all health outcomes[2] as compared to the physical environment we live in (10%), our overall health behaviors (30%), and access to quality clinical care (20%).

Given this reality, state Medicaid systems and Medicare Advantage plans are advancing new programs and initiatives to identify and mitigate these social determinants of health with the goal of improving member health and well-being, managing health care costs, and enhancing the member experience – all while improving the provider experience.

Providers and managed care organizations (MCOs) are making significant investments of time and resources to develop new interventions and approaches that identify the social and economic needs of individuals and families. In addition, policymakers are advancing health care policies and regulations that support identifying and responding to the social, economic, and behavioral barriers that limit individuals and families from achieving healthier lives.

Center for Medicare & Medicaid Innovation (CMMI) and SDOH
Department of Health and Human Services (HHS) Secretary Alex Azar recently outlined a new directive for integrating social determinants of health into health care. In outlining his vision, Azar reiterated the impact they have on high cost/high risk populations and the critical role connections to SDOH services have in establishing positive health outcomes.


States, in particular, are looking at different approaches to addressing SDOHs that are focused on better understanding the health needs of their population and providing individuals with pathways to connect to needed services and supports in the community. Two approaches, social needs screenings and referral/care coordination efforts, are most common in states that use managed care to administer their Medicaid programs. In fact, of the soon to be 40 states that provide Medicaid services through risk-based managed care plans, 35 include SDOH activities related to screening and/or referrals/care coordination in their managed care contracts. While there is wide variation in how these efforts are being implemented, we are seeing increased interest in taking these concepts from a small initiative or pilot to widespread practice. UnitedHealthcare is an active partner in supporting, convening, and engaging with state and local stakeholders to better meet the needs of our members and our communities.

Understanding the need

Under current federal rules, MCOs must make an effort to conduct a screening of each member’s needs within 90 days of enrollment into Medicaid. In many cases that screening requirement has not included a review of social needs, with the exception of a few specific populations. However, more and more states are now requiring MCOs to screen for the social needs of all members.

Efforts to collect SDOH needs data range from complex screening tools focused on key social and economic domains to care managers, social workers, and community health workers engaging with members in their homes and collecting first-hand information on their social and economic conditions. While the method of information gathering may vary, what tend to be consistent are the areas, or domains, of data that are priorities for screening for—housing, nutrition, transportation, and employment.

As part of a Medicaid Transformation initiative aimed at purchasing health, North Carolina developed its own statewide screening tool for all Medicaid members. Created in partnership with stakeholders and advocates, the state’s tool is comprised of 12 questions focused on four key social determinant of health: housing insecurity, food insecurity, access to transportation, and interpersonal safety.[3] As a new Prepaid Health Plan (PHP) in North Carolina, UnitedHealthcare will use this screening tool in our care coordination efforts to support those with identified barriers as well as those who are at risk.

Another example of a screening tool to collect SDOH data was created by the National Association of Community Health Centers. The Protocol for Responding to and Assessing Patients’ Assets, Risks and Experience or PRAPARE tool [4] is frequently used by providers in Federally Qualified Health Centers (FQHCs) in engagement with members to collect a wide range of social and economic information about, but not limited to income, employment, transportation, housing, and food.

Given the heightened focus on SDOH, new systems and technologies have emerged that are increasing connectivity to needed services and supports more efficiently and at reduced administrative burden. In the next post, we will discuss how the referral/care coordination process is changing.

[1] https://www.who.int/social_determinants/sdh_definition/en/

[2] http://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model

[3] https://files.nc.gov/ncdhhs/Updated-Standardized-Screening-Questions-7-9-18.pdf

[4] http://www.nachc.org/research-and-data/prapare/

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