Identifying & Addressing Social Determinants of Health

Social determinants of health (SDOH) are “the structural determinants and conditions in which people are born, grow, live, work and age.”[2] They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to healthcare.


Socioeconomic Barriers to Care

Consider, for a moment, some statistics[3]:

  • 28% of US adults reported that they had at least two chronic conditions
  • 26% of US adults said that they had experienced emotional distress in the past year that was difficult to cope with alone.
  • US adults were more likely than adults in all other countries to report that they were “always” or “usually” worrying about having enough money to buy nutritious meals and to pay their rent or mortgage.
  • 33% of US adults reported that they had had a cost-related access problem in the past year. US adults are the most likely to report financial barriers to health care compared to other countries.

Healthcare providers tend to think that people care about the same things they do – getting and staying healthy through a range of preventive care activities including annual well visits, chronic condition management, medication adherence programs and health education. However, we need to acknowledge that the same things aren’t often on the minds of the typical healthcare consumer. For them, healthcare is one of many competing priorities, and it is often put on the back burner when compared with the long list of things that is really on their mind

It is now widely recognized that the health outcomes of populations often are determined more by social factors than by medical care. 3

We’ve passed the point where more evidence is needed to prove the relationship between socioeconomic factors and health outcomes and are now at the point where early identification, screening and effective interventions and services are needed.

Health plans and providers need to assess members' access to healthy food, safe and stable housing, and healthcare, as these things are influenced by income and racial disparities and are related to poor health outcomes. Socioeconomic factors also contribute to chronic stress, which negatively impacts physical and mental health. But too often, socioeconomic barriers fall outside the benefit structure of health plans. One could argue that effective care cannot be delivered when we ignore life factors that have such an enormous impact on the health of members. It is critical for healthcare organizations to direct efforts and resources towards addressing issues of social inequities, diagnose problems, and remove barriers that negatively impact the health status and quality of life of their members. But how to do this when this type of information doesn’t come in on a claim? 

Know Your Members

Go beyond claims data and have conversations to identify life beyond the models.

Eliza develops strategies to assess and address social determinants of health in order to promote the health and wellness of health plan members. We do this by having a direct and open dialogue with members, with the intention of better understanding individual needs and barriers to care, and connecting members to valuable plan and community resources. 

An Eliza program assessing social determinants of health for Marketplace members revealed that people who report concerns about life necessities (food, shelter, safety) are:

  • 5x more likely to report having poor health
  • 2.5x more likely to report their health negatively impacting their work
  • 8x more likely to report high emotional stress
  • 40% reported having difficulty getting to the doctor

Our Social Determinants of Health module can be added to any Eliza outreach, from a welcome call with an HRA to a flu immunization reminder. The following topics are covered:

  • Life necessities (food, shelter, safety)
  • Mental and physical health changes
  • Health impact on taking care of others and employment
  • Money/financial worries
  • Caretaker stress
  • Housing stability over time
  • Access to transportation
  • Perceived ability to overcome problems and seek help

In order to get the most out of this activity, we recommend you follow these general guidelines:

  • Use multiple opportunities to collect Social Determinants of Health responses from members throughout their tenure
  • Monitor changes in responses over time
  • Offer immediate assistance to members reporting issues for which health plans have resources to address
  • Analyze member health behaviors in light of their responses




Eliza took this approach when partnering with Gateway Health to evaluate their Medicaid and Medicare population for socioeconomic barriers to care. Once barriers were identified, members were connected with a care manager who was able to provide support and plan or community resources. Over 30% of respondents said they were ‘moderately’ or ‘severely’ concerned with life necessities. These members are 2-3 times more likely to also report fair or poor health, compared to those with little or no concern for life necessities. 

Eliza Insights

We’ve found that the dually-eligible population is most likely to report high concerns about life necessities, followed by the Medicaid population and then Marketplace members (of which, about 85% are below 400% the federal poverty level).

It makes sense that those who are low income and older and/or disabled are most likely to experience socioeconomic barriers to health.

We also found that those who report high concerns about life necessities are 2-9% less likely to close clinical gaps than those who were neutral or had no concerns about food, shelter or safety. 


Those with concerns for life necessities are more likely to report that physical and emotional health problems affect their productivity, or their ability to do a good job at work, at home, or when caring for others. Not surprisingly, dually-eligible members are slightly more affected than Medicaid members, as age and disability status play a larger role in one’s ability to be “productive,” (as we define it). 

Emotional Health Impact on Productivity and Concerns About Life Necessities


Physical Health Impact on Productivity and Concerns About Life Necessities


How are you addressing social determinants of health for your low-income populations? Are you confident in your ability to catch members who don’t have access to life’s necessities? How can you leverage technology to identify and address social determinants of health? For more information on how Eliza can support you in answering these difficult questions, email or call us at 1-844-343-1441. 


[1]   "Community Healthcare Network Closeup" by jonny goldstein is licensed under CC BY 2.0

[3] Health Affairs, November 16, 2016

4 Taylor, L., Hyatt, A., Sandel, M. (2016, November 16). Defining The Health Care System’s Role In Addressing Social Determinants And Population Health. Health Affairs Blog.




Add new comment

Let's Connect