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By Ontrak
November 15, 2021

3 Keys to Addressing Common Gaps in Social Determinants of Health Programs

Leveraging AI to mass identifying social risks is not enough: Why personalization and human connection is critical to success

Despite the growth of data and programs that can provide support for common social determinants of health (SDOH), health outcomes for many are still negatively impacted by a range of social needs and risks that aren’t being adequately addressed. While screening for social risks and connecting people to services is necessary, it is not sufficient. Technology on its own cannot solve everyone’s SDOH challenges. Mass identifying risks among a population is only the first step, and simply matching individuals to canned resources will not solve the issue for every member.

So how do we effectively help individuals overcome social risks and related barriers to care? We do it through person-centered coaching that builds skills, knowledge, and self-efficacy through sustained engagement.

What are SDOH and how do they affect people?

SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health and quality-of-life outcomes and risks. When social needs are unmet, social risks occur that impact a person’s capacity to fully engage in their health, such as seeking appropriate care, attending provider appointments, and following treatment plans and health maintenance activities. When social risks occur there’s likely compromised self-efficacy.

SDOH factors include:

  1. Safe housing, transportation, and neighborhoods
  2. Racism, discrimination, and violence
  3. Education, job opportunities, and income
  4. Access to nutritious foods and physical activity opportunities
  5. Language and literacy skills

Social risks impact people’s health, well-being, and quality of life. Those who are affected by social factors are more likely to have chronic health conditions and lower life expectancy, and it can also affect their mental health.1

What do people with social risks need?

Often, those with social risks do not know how to overcome the risks themselves, and merely offering SDOH programs and resources alone is not sufficient to address all social risks.

Ongoing screening and sustained engagement are necessary to help individuals build the skills and knowledge needed to mitigate social risks long term. Solving social risks is not a one-time event, and the solution often needs to be tailored to the individual person. Needs and risks can arise at any time and without engagement, the social risk these members face will not get resolved. Those with identified social risks need to learn how to address those risks need to be taught how to address social risks on their own so they have the knowledge and skills to manage challenges independently when future issues arise.

Ongoing Assessments and Screening

Social risk can show up at any point in varying degrees of severity. The need can reveal itself subtly, so it is imperative to have a team of trained professionals who can identify risks and are closely connected to those who may be facing social risk challenges. When a problem is verbalized or suspected, evaluate the member’s baseline support and readiness to receive the support. It is important to brainstorm solutions and develop a plan. Making sure this is not a one-time screening, but a continuous conversation is a key part of the assessment.

Solutions Tailored to the Individual

They may need help navigating the health system and connecting to resources they will use based on their health conditions, cultural sensitivities, and social risk factors. For example, connecting a diabetic member facing food insecurity to a local food pantry may not be the best resource for that person if the pantry is not able to provide food that will meet their dietary needs. Likewise, this is true for individuals with hypertension or those who may be trying to manage their weight and need access to fresh and nutritious meals.

Sustained Engagement

Through human interaction, connection, and conversation, guide the member through milestones that solve the immediate roadblock. Additionally, prepare them with the knowledge, skills, resources, and the confidence to manage their physical and behavioral health conditions long term. Look at social risk from a deeper angle to identify the root cause that is contributing to the vulnerability.

How does Ontrak address social risk?

We address social risk at a deep level to promote durable outcomes through three steps.

  1. Deep Connection: Care Coaches build trust, inspire hope, and build a strong interpersonal relationship. Using motivational interviewing, therapeutic communication, cultural awareness, and robust clinical knowledge, we developed a person-centered, member-driven approach to addressing social risk. We discover what motivates the member, their back story, purpose, passion, and the goals driving them forward every day. This allows the Care Coach to listen for points in the conversation where social needs and risk are revealed.
  2. Identification and Resource Matching: Through that relationship, Care Coaches connect members with the right resource and teach them when and how to use it through decision-making methodologies. Care Coaches also help the member to discover strengths and build confidence to develop a strategy so when future needs come up, the member is able to solve them. The member takes accountability for solving issues and they realize their own ability to prevent or readily address future crises.
  3. Customization: Our approach is customized and supported through a homegrown database of resources (state, county, local, community, rural, urban, cultural, religious preferences, etc.) allowing us to tailor resources to solve individual risks. Through the customization process, the Care Coach takes a focused approach to tailoring the resource using the database. Furthermore, our resource database is curated to our membership, who are specifically struggling with co-occurring behavioral and physical health issues. Care Coaches also frequently reach out to resource contacts within these geographical areas to coordinate resource alignment.

We are enhancing our solution to measure social risk outcomes, better identify members with social risk and stratify their risk level to determine what type of resource they need. If a resource is not the right match for a particular individual, we know that they will not use it and the cycle of unaddressed socials risks will continue to perpetuate.

What matters to the member is just as important as the social risk. Helping members overcome social risks just one piece of what we do. We treat members’ underlying behavioral health conditions, connect them to care, and support them through treatment. We have the ability to improve clinician and member experience, lower costs, and improve outcomes through deeper engagements. High-touch human connection and engagement, in conjunction with data and technology, are key to solving social risks and providing proven, durable outcomes.

Click here to learn more about our proven approach and validated outcomes.

To learn more about how Ontrak helps our members overcome social risks and barriers to care, view our session, “Addressing Gaps in SDOH Support Programs”, presented at the HealthPayerIntelligence 2021 Virtual Summit.

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