Healthcare Short: SDOH Predictive Analytics for Personalized Patient or Member Outreach
Published Feb 01 2023 02:00 PM 1,990 Views

Situation Overview

According to the World Health Organization and the Centers for Disease Control and Prevention (CDC), social determinants of health (SDOH) are the non-medical factors that affect health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. The forces include economic policies and systems, development agendas, social norms, social policies, climate change, and political systems.


Business Challenge 

Providers and payors can take into consideration SDOH parameters when caring for patients and members. Social determinants of health have a major impact on people’s health, well-being, and quality of life. Factors such as safe housing, transportation, neighborhoods, education, job opportunities, income, access to nutritious foods, and physical activity opportunities all contribute significantly to the well-being of any individual. That is why SDOH is one of the top 3 priorities areas in Healthy People 2030.

Public health organizations and their partners in sectors like education, transportation, and housing need to take action to improve the conditions in peoples’ environments.


Solution Overview 

This solution uses publicly available SDOH information from the Agency for Healthcare Research and Quality ( and patient/member data to develop a model that will identify individuals with high SDOH risk scores. It starts with using the FHIR resource for Condition and identifying persons with chronic conditions such as asthma, diabetes, and cardiac conditions.

The solution then matches these conditions with available local or virtual services recommended by CMS to address those conditions. Using communications tailored to your organization, this solution will outreach to these cohorts, referring them to relevant services.

Additionally, when a patient has a , a notification will appear on their Patient 360 (unified view) in Dynamics 365 (CRM). The Virtual Assistant will alert anyone looking at the record so they can close that care gap by receiving the corresponding intervention. The SDOH dashboard allows the agent to quickly search for pre-approved service providers and text this information to the patient on demand. 


Business Outcomes 

​​​​​​​Implementation of this solution as a standalone or integrated into a bigger framework can improve your care of patients and members as well as:

  • Allow non-licensed staff to assist with SDOH interventions
  • Increase patients’ participation in recommended treatments
  • Improve your performance in value-based reimbursement models
  • Streamline closing of SDOH care gaps


A solution like this can greatly impact the wellbeing of people with these conditions helping them get the services they need that are approved and appropriate for their care. This creates better patient outcomes and positive patient experiences with their provider.



Thanks for reading, Shelly Avery |EmailLinkedIn 


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Sources: Social Need: New HEDIS Measure Uses Electronic Data to Look at Screening, Intervention - NCQA







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Last update:
‎Feb 02 2023 08:48 AM
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