Integrating SDoH Data into Population Health Dashboards and Data Outputs to Improve Health Outcomes

Social Determinants of Health

There is overwhelming evidence to suggest that social and behavioral determinants of health (SBDoH or broadly called SDoH) are critical drivers of health and well-being. Medical care only accounts for around 20 percent of health outcomes, whereas the physical environment, socioeconomic factors and health-related behaviors broadly called the SDoH, account for about 80 percent of outcomes[i].

Addressing health disparities proactively for sub-populations and individuals requires SDoH-derived insights that are truly actionable, so that care teams can prioritize the most impactful interventions.

THRIVE[ii] (Tool for Health and Resilience in Vulnerable Environments) identifies 12 community determinants of health and safety, grouped in 3 interrelated clusters:

  1. Social- cultural environment(people)
  2. The physical / built environment (place)
  3. The economic/ educational environment (equitable opportunity)

Given that a patient’s care journey is 80% dependent on non-clinical factors, we need to account for these drivers in our population health (PH) models. Healthcare organizations pursuing value-based care must go beyond standard claims and medical data and integrate data sources that measure SDoH to effectively treat and achieve whole person, patient-centric care.

The pathways between SDoH risk factors and health outcomes are complex and varied. Interventions like these require strong partnerships with community-based organizations, community health workers, and case managers. With SDoH data-driven insights, AssureCare provides complete Care Management for Payers and Providers, which includes:

Real-time communication and coordination among all the members of the care team.

Create Personalized Treatment plans using relevant health history, disease status and risk factors that may impact member outcomes.

Preventative Care to identify, stratify and monitor high-risk population to ensure preventative care and appropriate treatment options are available.

Impact Reporting to efficiently document and report on the impact of programs and targeted interventions.

AssureCare’s risk stratification analytical data and technology can more precisely identify sub-cohorts of patients who will benefit from a specific intervention, manage a variety of chronic conditions such as Diabetes, Asthma, Opioid addiction, Mental health, high-risk maternity, and can be used to improve overall patient health and wellness.

The incorporation of SDoH data elements enables practitioners to provide patient-centric care through a deeper understanding of social risk factors.

AssureCare has spent years creating the most SDoH-robust dataset in the industry, keeping in pace with the latest evidence-based practices. We provide the framework for understanding how structural drivers play out at the community level to impact social determinants, leading to health and safety outcomes. Our platform fosters community engagement as well as enables practitioners to assess the status of community determinants, prioritizing them, and taking action to change them to improve health, safety, and health equity.



Dr. Ankit Rohatgi

Chief Clinical Officer, MD