Driving the Data to Address Social Vulnerabilities in Healthcare



Improving the quality and efficiency is a priority for healthcare, but health is more than just medical care.  We are now in an era of integration and (attempted) interoperability, with most providers investing in stronger data collection and sharing efforts.  This vast network of data enables physicians to access the patient information they need in order to make well-informed decisions to influence positive clinical outcomes.   


But what about the social aspects that impact these clinical decisions and outcomes? Social determinants of health (SDoH) are defined by the World Health Organization, as “the conditions in which people are born, grow, live, work, and age.”  We’ve all seen the statistic that as much as 80% of health outcomes are driven by social and environmental factors, and most clinicians would agree that health outcomes are affected by patients’ conditions outside the clinical walls. However, healthcare is missing a domain of expertise and current accountability around SDoH.  A Medical Economics article states “the bottom line is that when physician practices are aware of their patients’ needs beyond medical care, they’re able to provide better care and patients are better able to participate in achieving their own health goals.”  Focusing on SDoH data and analytical decision support tools will provide expertise, accountability, and give healthcare the ability to create a real business strategy to impact population health. 


Many clinicians are already conducting social assessments of their patients and would claim they are aware of the social barriers they are facing, especially in the primary care setting. But assessments have limitations. What if we go beyond the assessment process?  What if we can use machine learning analytics, geospatial data, and natural language processing to curate this information into a form where it can be used proactively to prescribe social interventions? These efforts would help to:  

  • Standardize data collection efforts for all individuals, not just those that that fill out an assessment 

  • Track changes to social needs and barriers to care over time 

  • Provide population insights to understand strategic direction as it relates to integrated social and clinical care initiatives 


With SDoH analytics, we can affect many aspects of our healthcare system, and companies like Base Camp Health are here to make an impact. To implement SDoH effectively, the process needs to be simplified. We need to make it easy for our overworked clinicians, community health workers, and case managers to understand each patient’s social risk and prescribe actionable insights at the appropriate point-of-care. Furthermore, best practices in measuring and monitoring these social interventions is a necessity to propel these efforts forward.  


This focus goes beyond the walls of the hospital or the health insurer. It is imperative that all healthcare organizations have a clear understanding of the communities they serve; they need to know the social factors that influence their patients’ or members’ health and empower the health care ecosystem to effectively address possible barriers. The National Academy of Medicine agrees that “with so many unknowns about the use of SDoH in clinical care, having data for measurement and evaluation of interventions is essential.” Right now SDoH are a recommendation, and we know it will have to become a requirement before it is fully integrated into our healthcare system. But the good news is that new payment models are prompting interest in the SDoH and that frameworks for integrating SDoH are emerging and tracking now SDoH will positively impact the bottom line. We are on the brink of something that will change healthcare for the better and Base Camp Health believes that acting now is imperative in supporting our most vulnerable populations and scaling the summit to better health outcomes.