How personalized intervention uncovers social determinants of health

By Maren Beus, MBA, RN
Vice President, Clinical Operations and Strategy, Engooden Health

In the United States, efforts to improve health outcomes have traditionally come from within the healthcare system. However, in recent years, it's become increasingly clear that clinical care has less influence over health outcomes than where someone lives, works, and the food they eat. Approximately 95 percent of U.S. health expenditures go toward medical care, highlighting the limited impact medical care has on individual health outcomes.

Resources such as safe and affordable housing, access to education, public safety, availability of healthy foods, among others enhance the quality of life and significantly influence health outcomes. For healthcare providers and payers, understanding a patient’s social determinants of health (SDOH) is critical to helping them improve their health, especially if they suffer from chronic diseases such as depression, hypertension or diabetes. In many cases, the best way to discover their SDOH is through personal intervention outside of clinical office visits.

The Social Determinants Gap

Too often, social determinants gaps prevent clinicians from getting the complete picture of a patient’s health. A physician might not know all the factors in play - what may look like a patient’s refusal to comply with treatment could be an inability to follow their care plan. There are countless reasons why this happens. Perhaps a patient can't afford medication or transportation to follow-up appointments, or a language barrier is causing a misunderstanding that prevents them from following through with a prescription or therapy.

Addressing the social determinants gap is especially vital for chronic disease management patients and can keep their health from deteriorating and becoming high-risk. Consistent, trust-based patient engagements from health professionals paired with customized care plans that meet unique patient needs allow them to feel like they have a voice and are well informed. It gives patients a safe space to ask questions, express concerns, and request advice from health experts in a more comfortable setting.

A Personal Touch

Despite the social, economic, and environmental influences on patient health, providers can do more to address patient needs. For example: personalizing outreach to ensure patients pick up and understand prescription requirements or have transportation to outpatient therapy. Many patients, particularly the elderly or those who act as caregivers for others, are also susceptible to the health impacts of loneliness. The Center for Disease Control reports social isolation significantly increases a person’s risk of death from all causes. Providers who extend care to patients between clinical visits can alleviate the symptoms of loneliness with a simple check-in.

Not all people are the same, and, for many, if they don't feel they have an ally in the medical system, they won't be able to reach desired health outcomes. Consider a patient who has been abused at home or recently lost a job; they may not be comfortable sharing this information during a routine screening. These details are vital social determinants of health but are often best uncovered through more personalized conversations that foster a genuine human connection outside of the clinical setting.

The first step to closing the social determinants of health gap is identifying the less obvious factors influencing a patient's health. With more patients living with chronic disease in the United States than ever, providers need help uncovering all social determinants and getting patients the holistic care they need to truly improve outcomes and reduce cost.

How Engooden Can Help

Our care navigators help patients navigate the healthcare system, increasing retention in a competitive market, also granting physicians better visibility into the physical, social, and economic barriers to care that their patients may experience. By offering services to more patients without the need to take on additional risk, health systems working with Engooden can more effectively convert a larger portion of the patient population into well-managed patients.

We conduct monthly phone calls and check-ins with patients between office visits to help them:

  • Improve quality of life by reducing blood pressure, weight, total cholesterol, HbA1c, and/or by meeting other physician-identified health goals
  • Increase access to care between office visits; care that follows them closely over time
  • Manage medications and help with prescription refills and side effects
  • Assist with appointment scheduling
  • Lend a listening ear and develop trust, particularly helpful for isolated patients

Engooden’s mission is to empower patients to take control of their health and improve their overall quality of life. We’re setting a new standard of care that we believe all patients deserve.