By Robin Stawasz

It has been well accepted that social drivers of health (SDOH) have a tremendously significant impact on health outcomes for us all (note – I prefer “social drivers” to “social determinants” as these issues influence, but do not dictate, outcomes). These factors can influence treatment success to a greater extent than the actual medical intervention itself. Thus, accounting for SDOH in program design, care planning, and quality measurement is absolutely critical. 

But, which SDOH matter? What do we measure? How do we measure it? We are still working on figuring this out, but there are indications. Researchers at Massachusetts General Hospital and the University of California have identified 8 social factors that predicted an earlier death for adults 65 and older, including social isolation factors and feeling a lack of control. Johns Hopkins’ ACG System, the world’s leading population health software and a driver behind Acclivity’s predictive analytics platform, incorporates social factors into their data analysis down to the patient level. CMS has developed the Health-Related Social Needs Screening Tool as part of their innovative Accountable Health Communities payment model. So, if we are getting better at measuring the SDOH that matter, what do we do once it is measured? This is where interdisciplinary, home-based care providers are ahead of the curve. Medically based skill sets may not be the most effective here. Instead, non-medical and even non-clinical experts can be both the most effective and the most efficient. Teams that fully incorporate and empower these professionals will have the greatest impact on outcomes, costs, utilization, and patient satisfaction. Payers must continue to financially support this care model design, which CMS does seem to be embracing to at least a limited extent. The returns on such an investment are definitely worthwhile.

If you would like help making sense of SDOH, Acclivity is here for you – please contact us.

Source Material: “Researchers ID 8 Social Factors the Lead to Early Death in Seniors” by John Roszkowski posted by McKnights Long-Term Care News on February 14, 2023 (

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