Addressing social determinants of health (SDoH) has enabled one special needs plan to improve health outcomes for members and has led to a decrease in emergency room visits, inpatient admissions, and inpatient lengths of stay.

Dennis Mihale, M.D., chief medical officer, Upward Health, recently presented a session at RISE’s virtual Special Needs Plan Leadership Summit and shared the strategies Upward Health, a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs, has implemented to address SDoH.

SDoH, which include a broad range of personal, social, economic, and environmental factors, play a critical role in individual and population health, and addressing issues such as food and housing security, access to transportation, education, and literacy, can make all the difference, explained Mihale.

“Social determinants of health really is an opportunity to move the needle,” he said. “These factors may be more important than what we might deliver in an office.” In fact, 80 percent of health outcomes are related to physical environment, social determinants, and behavioral factors, noted Mihale, whereas only 20 percent of health and wellbeing is related to access to care and quality of services.

Although individuals with special needs can be especially difficult to engage in the health care system to coordinate care, Upward Health has discovered key strategies that have made a significant difference in how they address SDoH and their care delivery as a whole. Indeed, by addressing SDoH, Upward Health saw a 42 percent reduction in total acute care days resulting from a decrease in emergency department visits, inpatient admissions, and inpatient lengths of stay.

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In his presentation, Mihale shared operational best practices for special needs plans to best address SDoH:

1. Develop a relationship of safety and trust. Patients must be able to trust who they work with, whether it’s with a nurse, doctor, social worker, or community health worker. “The number one driving force of good outcomes is developing a relationship of safety and trust. When they develop that relationship, things change. The needle starts to move.”

2. Let patients tell you their needs. Too often, providers will try to tell patients what their needs are, but there’s more power in listening, explained Mihale. Give patients the opportunity to define their own needs and share what they would like to address.

3. Address mental and behavioral health issues. If a patient struggles with mental or behavioral health, it cannot be ignored. Taking on issues such as addiction is extremely tough, but vital, , explained Mihale. “If you cannot address it, find someone who can.”

4. Be proactive. Addressing SDoH is high-touch and it requires frequent communication with patients. “This isn’t seeing a patient once a quarter, not even once a month. It’s high-touch and it’s expensive, but we leverage a lot of less-expensive but powerful resources.”

5. Leverage community resources and build partnerships. A great method to improve patient outcomes and reduce costs for high-risk, high-need patients is to identify gaps in care and then partner with community resources that can fill those gaps, such as local community-based organizations, housing authorities, or community health workers.

6. Practice poverty simulations. If you can’t relate to poverty, it’s important to execute a poverty simulation for executives and staff to understand the realities and challenges faced by low income families. The simulations not only raise awareness but also highlights SDoH, stereotypes, and the responsibility of the community.

7. Address adverse childhood events. A huge roadblock to addressing SDoH can be adverse childhood events, noted Mihale. “It leaves scars and trauma, and until you address them you may have trouble engaging the patient and therefore have a problem delivering the best possible care.”