Collecting Social Needs Data to Drive Equity and Performance

By Knitasha Washington
President & Founder
ATW Health Solutions


This article suggests that a data-driven approach to diversity, equity and inclusion (DEI) is essential when companies are seeking a global workforce and consumers. The diverse needs of both the workforce as well as consumers need to be considered in strategic plans to improve DEI. When it comes to equity, health equity plays a role in business and demands the attention of DEI business leaders. A health equity strategy can be interwoven into all businesses—from the factory floor to the office cubicles all the way up to the board room—to address causal factors effecting health outcomes such as housing, food, transportation, and financial needs. Achievement of business outcomes and revenue targets require the integration of human and operational factors that drive the entire ecosystem in a global marketplace. Business leaders are increasingly acknowledging employees’ social factors affects their health, which in turn affects multiple business factors including employee and business productivity, benefits, and insurance costs; all of which affects the organization’s financial performance. People’s social factors impact80% of their health outcomes and are known as the social determinants of health. These social determinants of health become more significant in communities that are geographically located in urban or rural areas that employ a disproportionate number of lower-income workers. This article highlights the social determinants of health and the use of an innovative e-tool to capture data as part of an equity strategy to improve the health of workers and consumers to drive organizational performance.

Key words: equity, health equity, social determinants of health, data collection, health care quality

Collecting social needs data to drive equity and performance

Research shows social determinants account for up to 80-90% of a person’s health outcomes (Magnan, 2017). Whether an employee is struggling with transportation to work or is living in a food desert, the focus on capturing real-time data to identify and address social needs is pivotal to improved productivity. Achievement of business outcomes and revenue targets require the integration of human and operational factors that drive the entire ecosystem in a global marketplace. Understanding diverse cultures, communications and communities is an imperative to ensure business success. Organizations ranging from large private commercial entities that are self-insured to smaller community-based organizations, business leaders need data-driven interventions that support the workforce as well as the consumer and local community. Within health care institutions, this is further complicated when geographically located in underserved communities that reside both the workforce and the patient populations.

To define many of the social factors that impact health outcomes, the World Health Organization (n.d.) refers to them as social determinants of health (SDOH) as “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 SDOH includes housing needs, food and clothing insecurity, lack of money or resources for medications, utility bills etc. Health inequity, also referred to as health disparities, is defined by the Institute for Health Equity (n.d.) as, “Unfair distribution [of power, money and resources] creates avoidable health inequalities…”

In the United States rural, low-income and racial/ethnic minorities experience decreased access to high-quality healthcare as evidenced by decades of research citing health disparities, and policy decisions that had a disregard for social determinants.

The Robert Wood Johnson Foundation reports that the social determinants of health(SDOH) account for as much as 80% of health outcomes (Manatt & Phillips, 2019, p. 1).These factors negatively affect State Medicaid programs (the U.S. safety-net insurance program) and their ability to control the cost of healthcare delivery. According to the Centers for Medicare and Medicaid Services (CMS) (2019), healthcare is one of the largest vertical business markets in the United States and accounts for $3.8 trillion and17.7% of the gross domestic product. This further magnifies the importance of DEI business leaders to understand and recognize the importance of capturing and addressing social needs of employees.

Health inequities account for millions in annual losses to the U.S. economy each year. According to Turner (2016, pp. 20-29),

“Healthier workers have fewer sick days, are more productive on the job, and have lower medical care costs. A healthier population saves everyone in insurance premiums and health-related public spending. Beyond the toll in avoidable human suffering, we estimate disparities in health in the U.S. today represent $93 billion in excess medical care costs and $42 billion in untapped productivity, for a total potential economic gain of $135 billion per year.”

A recent example of the application of social determinants of health intervention is illustrated by UnitedHealth’s recent purchase of apartments near Phoenix, AZ for 60 former homeless persons enrolled in Medicaid, to lower the cost of healthcare by taking care of their members’ social needs. UnitedHealth is America’s largest health insurer with a market capitalization of $240 billion ranked 7thon the 2020 Fortune 500. This demonstrates the organization’s understanding that an individual, whether an employee or patient, social needs cost the healthcare system a significant amount of money and decrease revenues for their business.

States can mandate business leaders of Managed Care Organizations (MCOs) to integrate social support into health plan care management and address the social needs of their members as part of their healthcare management obligation. Clearly, this has a financial impact that demands attention and creates an opportunity for CDOs to leverage a culturally and linguistically appropriate strategy to address equity. Currently, 24 states require MCOs to perform social determinant screening for their beneficiaries as part of their care management recognizing that addressing the social needs of their constituents has a positive effect on health outcomes.

Historically, the United States healthcare payment system was driven by a fee-for-service payment model which pays a medical provider for the amount or volume of medical services provided. Therefore, most physician offices have a medical model of care that does not actively address social needs of patients. New policy reform is now driving payment based on quality of care, referred to as value-based payment, which can result in shared savings payments to providers. Value-based payment models pay for quality care which requires providers to achieve targets specific to a defined set of health outcome measures. The shift from fee-for-service payments to value-based payments makes screening for social determinants imperative, especially for those beneficiaries with high-costs and high-needs. However, many solo and small practices are challenged to integrate the requirements to transition to value-based care because of the lack of technology, qualified, well-trained staff, unreliable revenue cycles, private vs. public insurance mix and high percent of unpaid receivables from uninsured patients.

The Issues

Business leaders are increasingly acknowledging employees’ social factors affects their health, which in turn affects multiple business factors including employee and business productivity, benefits, and insurance costs; all of which affects the organization’s financial performance. Therefore, capturing SDOH data for vulnerable patients who may also be members of the workforce improves health as well as business outcomes. Additionally, the shift to value-based payments for health care providers creates a business case for collecting this data. SDOH data provides a more holistic view of patients by looking at factors that influence well-being in tandem with medical care to decrease costs and improve quality.

Given the profound impact social determinants have on health outcomes, it is also important to understand the issues related to data collection and integration into ambulatory workflows and electronic medical records. Healthcare providers today are becoming increasingly aware of social determinants for health and the need to utilize both individual and population health aggregate data to assist in understanding the underlying challenges at the point of care. While many providers express concern that social determinants are not within their span of control, acknowledging the need to collect and use SDOH data to better understand the challenges patients face is widely accepted. Limited results have been documented supporting the collection of SDOH data and the integration of both social and medical data to improve outcomes.

HealthCare Dynamics International (HCDI), a healthcare management and technology firm committed to quality improvement, leveraged its experience, began to address this issue in collaboration with CMS’ Transforming Clinical Practice Initiative (TCPI), a large-scale quality improvement project to improve outcomes in ambulatory care environments. HCDI focused on working with clinicians and medical practices across the country through a pilot program to prepare their business for alternative payment models by implementing an e-tool, called Caring for Your Health (CFYH), for SDOH data collection. Since research shows patient outcomes are significantly influenced by SDOH, one of the CFYH e-Tool integration goals was to make SDOH data collection and utilization easier to integrate into a clinical workflow in the ambulatory medical practice setting. The purpose of using the CFYH SDOH e-Tool for the pilot program was to understand challenges and successes in workflow redesign and real-time data collection to capture actionable social needs that supports person-centered care coordination of SDOH support services. The primary objective of the pilot was to identify the SDOH issues that patients were experiencing and develop strategies to integrate patient’s needs into their care plan thus addressing health disparities.

Method & Procedures

HCDI piloted a patient-facing social determinants screening e-tool, the Caring for Your Health (CFYH) SDOH e-Tool, across multiple medical practices to identify and address social determinants of health and health equity. The CFYH SDOH e-Tool was initially designed by HCDI in its work supporting primary care small business practices to address the social needs of patients with diabetes. HCDI’s CFYH SDOH e-tool was designed to capture real-time social needs that impact patient and population health and supports implementing data-driven, targeted interventions aimed at improving health and wellness. The CFYH e-tool captures up to 23 data fields organizing patient level data that can be easily mapped to ICD-10 Z coding system (CFYH Tool and Z codes: Z55-Z65 persons with potential health hazards related to socioeconomic and psychological circumstances). This pilot study was not an IRB approved research study but data collected with a rapid-cycle improvement project for the purpose of learning and sharing.

SDOHData Collection and Utilization

During the pilot program, HCDI partnered with medical practices across the United States implementing CFYH SDOH e-Tool for data collection and utilization. The licenses for the CFYH SDOH e-Tool were provided at no charge to the pilot participants. SDOH data related to housing, access to food, access to medication and transportation resources was collected from patients in clinic settings using three primary source points: 1) an iPad 2) integration with a patient portal via an electronic medical record (EMR) or 3) paper surveys. For each SDOH data element, validated questions were asked to assess underlying factors influencing chronic conditions. After SDOH data was collected, information including patient demographic data such as Race, Ethnicity and Language (REaL) data was compiled by the care team along with the patient’s location, chronic health conditions and community resources utilized.

Research was conducted regarding the availability of Government and community resources for the pilot program sites. Information about these resources were grouped using categories of temporary housing, food resources, transportation services, health insurance enrollment, county resources, utility assistance, veteran services, referral services, and easy access pharmaceutical needs. Phone calls were made by the care team to confirm the legitimacy of the resources identified as well as the qualification process for the patients to receive services. Once confirmed, the information was then categorized into sub-sections for care team member’s use with patients who screened positive for SDOH needs.

Members of the care team known as care coordinators contacted patients and provided literacy and navigation assistance and a plan to access community resources. A timeline was established to give patients an opportunity to engage and obtain the resources provided to close the gaps of specific social needs. A follow-up call was implemented by the staff to ensure the patient followed through with the given resources. Prompt communication and frequent follow-ups were part of the support process to successfully close each identified gap.


A total of 3,510 patient assessments were made using CFYH SDOH e-Tool during the pilot period across four physician practice networks. More than 45% of the patient population in each participating pilot site reported at least one SDOH and one site reported 90% of the target population reporting at least one SDOH. While the top reported SDOH’s varied by site, food insecurity was consistently identified as one of the top three SDOH concerns.

Gap closures for the targeted population averaged 30% of all cases. The lack of sufficient updated patient contact information was cited as a concern and limitation to increasing the number of gap closures. Examples such as the incorrect patient phone numbers, disconnected phone service, or full voicemail boxes, made it challenging to reach the patient.

Improved outcomes for the clinical practice sites were also demonstrated. Table1summarizes the results of one of the four participating sites that reported promising results in three performance measures including,

  • a decrease of 10.34% in non-emergent emergency room visits (NER),
  • inpatient utilization (IPU), down nearly 25%, improving performance from <25 to25th compliance rate percentile, and
  • an increase of nearly 6% in 14-day follow-up visit after inpatient discharge(FU14).


Optimal strategies to improve employee and patient health outcomes are ones that are well informed with data rooted in human centered, actionable and real-time data collection. This enables a comprehensive strategy that best meets the needs of the workforce who then are best equipped to serve the needs of the consumer and the community. This builds good will and business brand. In the TCPI pilot, the CFYH SDOH e-Tool demonstrated its effectiveness in capturing real-time actionable data from patients in a medical practice. The CFYH SDOH e-Tool provides one example of a way in which SDOH data can be collected that minimizes administrative staff time and preserves the integrity and privacy of the consumer patient.

It is hypothesized after a continued process of consistent screening for social determinants, patients’ social concerns will be improved as well as overall clinical health outcomes. With results showing that up to 80-90% of health outcomes are a result of social, behavioral and economic factors, identifying and understanding social determinants of health has the potential to drastically improve quality outcomes.

The ease of application of the CFYH SDOH e-Tool within medical practices with low resources suggest its purpose can be applied across multiple business types to capture real-time social needs data on a workforce in multiple locations. In light of the trend of working from home due to COVID-19, the CFYH SDOH e-Tool may be privately deployed for employee assistance programs to glean data to support employees achieving greater work satisfaction. Creating an atmosphere that offers employees the opportunity to share their social needs builds staff loyalty and retention. The CFYH SDOH e-Tool questions may be customized to address specific needs unique to an organization’s workforce due to the geographic location, industry, season of the year or health needs.

Efforts must be made to better understand the underlying factors that influence health disparities as well as health outcomes. The collection and use of SDOH data is a promising practice that can be used to improve overall health outcomes. The implementation of the CFYH SDOH e-Tool alone raised awareness of the pervasiveness of issues related to patient outcomes. The use of care team members to collect community level data and perform patient follow-ups created a systematic approach to the work by eliminating or decreasing social concerns which resulted in health improvements. This is a critical element required in a value-based care delivery and payment environment.

These efforts are a start but are not enough. If all States mandate MCO’s to help low-resource providers address social needs this would be a step in the right direction for addressing health disparities, equal access to high-quality care and lower costs. U.S. policymakers need to confront the real and perceived barriers to healthcare and find systemic solutions to provide equal access to quality healthcare for all. Chief Diversity Officers leading organizations across a broad spectrum of industries are summoned to drive health and well-being in an equitable data-driven way for a growingly diverse workforce.

Summary and Recommendation

As healthcare continues to transition to a value-based care system, the CFYH SDOH e-Tool aligns with a systems approach to collecting SDOH data and addressing social needs that impact health outcomes. Doing such not only improves patient outcomes but also performance outcomes in medical practices providing a return on investment. Improving both patient outcomes and organizational performance can ultimately have a positive downstream economic impact as well.

Whereas the CFYH SDoH e-Tool was initially piloted in medical practices, it can also be used for staff in non-medical organizational settings. It is proposed that by electronically screening for and addressing social determinants, people have a higher probability to achieve improved health and well-being. Due to the significant influence social determinants have on overall health outcomes, this can translate to improved worksite productivity.


Centers for Medicare and Medicaid Services. (2019).National Health Expenditure Accounts.

Institute of Health Equity. (n.d.)Action on the Social Determinants of Health.

Magnan, S. (2017). Social Determinants of Health 101 for Health Care: Five Plus Five. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington,DC.

Manatt, P., & Phillips, L. L. P. (2019).Medicaid’s Role in Addressing Social Determinants ofHealth.,services%20not%20covered%20by%20Medicaid.

Turner, A. (2016). The business case for racial equity.National Civic Review,105(1), 21-29.

World Health Organization (n.d.).Social determinants of health.