health determinants

Effective Care Coordination Addresses All Determinants of Health to Improve Health Equity

Although health outcomes are influenced not only by medical conditions, but the behavioral and social factors that impact a patient’s well-being, healthcare systems have traditionally focused their efforts primarily on physical and behavioral health. Social determinants of health (SDOH), however, can impact as much as 80 percent of health outcomes and can be a significant cost driver. Effective care coordination should include social determinants as part of a whole-person approach to care to improve the health of both individuals and populations.

What Are Social Determinants of Health?

Social determinants are the conditions and circumstances in which individuals are born, grow, live, work, and age, and encompass a wide range of social, economic, environmental, and cultural factors that pay a crucial role in shaping an individual’s health and well-being. Recent Kaiser Family Foundation research shows that “a broad array of factors within and beyond the health care system drive disparities in health and health care,” including a wide range of social determinants:

  • Economic stability
  • Neighborhood and physical environment including housing, transportation, and zip code
  • Education
  • Food security and access to healthy food options
  • Community, safety, and social context including support systems and community engagement
  • Health care system, including not only quality care, but access to linguistically and culturally appropriate provider and pharmacy resources

Why Do Social Determinants Matter When Coordinating Care?

Social determinants—such as race and ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location—can lead to discrimination and health disparities among different population groups and contribute to a person’s ability to achieve good health and wellness. According to the World Health Organization, health and illness follow a social gradient: the lower the socioeconomic conditions of an individual, the worse the health. In addition, negative social determinants are costly and reduce the overall quality of care and population health, resulting in higher healthcare expenses, lower productivity, and even premature death. 

Addressing differences in SDOH can improve health equity by boosting access and opportunity for every person to achieve his or her highest level of health regardless of personal characteristics, circumstances, or location. Care coordination technology makes this possible.

Effective Care Coordination Includes Social Determinants

Care coordination can be effective at mitigating the negative effects of social determinants. By connecting medical and behavioral health providers with community resources, care coordination enables whole-person care by addressing social determinants as part of a comprehensive, holistic care methodology. Organizations can have a positive impact on health outcomes by addressing these disparities, especially for vulnerable populations such as Medicaid, Medicare Advantage, and dual-eligible populations.

Care coordination that integrates social determinants can make  organizations more effective by:

  • Forging partnerships across payers, providers, and the community to collaborate and facilitate access to appropriate medical, behavioral health, and social services
  • Understanding and orchestrating comprehensive care for the health needs of each individual through assessments, care plans, and referrals as part of a comprehensive 360° treatment plan to close gaps, support transitions, and prevent unnecessary care
  • Improving care quality through automated workflows that ensure consistent care according to organizational best practices
  • Early identification of risk factors for early intervention to improve outcomes and reduce risk
  • Engaging with individuals to improve health literacy and empower individuals to make more informed decisions

Incedo Integrates Social Determinants for Effective Care Coordination

InfoMC has more than 25 years of experience addressing social determinants as part of a comprehensive, whole-person approach to care. Ideal for Medicaid and Medicare Advantage populations and preconfigured to support the Special Needs Plan (SNP) model of care, the Incedo care management platform integrates all aspects of care across the full continuum of medical and behavioral health providers and community services. Our innovative technology helps you coordinate care, proactively eliminate barriers, and manage even the most complex individuals to ensure health equity and improve outcomes.

Learn more about how Incedo integrates care management, behavioral health management, and utilization management to help you more effectively manage care.


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