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Social determinants of health—the conditions in which people live, learn, work, play, and worship—are inextricably linked to an individual’s physical health. Emerging evidence suggests addressing health-related social needs can improve health outcomes and reduce cost. Unmet social needs, such as food or housing insecurity, may increase the risk of developing chronic conditions, reducing an individual’s ability to manage these conditions, which may lead to avoidable health care utilization.

Outside of the traditional role of the health system, the knowledge to appropriately match patients to services in the community is often locked in paper documents, outdated binders, and individuals’ minds. With systems increasingly bearing risk and losing money on treating uninsured, Medicaid, and increasingly, high-deductible populations, streamlining this process and identifying these gaps is an important piece of any strategic plan. Health systems are beginning to invest in partnerships and technologies to identify the right community partnerships and make the connections.

Health equity means increasing opportunities for everyone to live their healthiest life possible. Health systems can, and should, do more with scalable digital solutions to make progress on these measures and more:

• 2x more Black babies die before their first birthday than white babies. 3x more Black women die of pregnancy complications than white women.
• <15% of children and families living in poverty, and with a mental health care need, receive mental health services; even fewer complete treatment.
• 57% of patients have moderate-to-high risk for at least one unmet social need. These patients have higher ED and inpatient utilization.*

Prioritizing equity is not only the right thing to do, it can also yield positive financial benefits. For every 100K underserved patients, health systems are leaving up to $36M on the table by failing to act. For example, health systems can:

• Target interventions through improved data from self-service patient intake and customer relationship management tools, social and behavioral health screening, and social and population health analytics.
• Reduce unnecessary ED visits and hospitalizations with community resource referrals and direct services, such as nutrition support.
• Increase access, capacity, and revenue by offering accessible remote monitoring, on-demand behavioral health, telemental, and tele-medication assisted treatment (MAT), and non-emergency medical transportation.

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