This post was written by Casey Piatt, BSN, RN, AMB-BC, Clinical Care Guide at apree health
The National Institute for Health defines Social Determinants of Health (SDOH) as the social, economic, and physical conditions in the places where people are born, live, learn, work, play, and age that can affect their health, well-being, and quality of life. SDoH includes factors such as education level, income, employment, housing, transportation, and access to healthy food, clean air and water, and health care services.
The categories included are non-medical factors that impact a person’s health and longevity. These factors encompass conditions such as: food insecurities, affordability of basic necessities , housing, utility cost, transportation barriers, childcare cost and access, and discrimination.
Why are Social Determinants of Health important to us?
SDOH contributes to significant health disparities and inequities in affected populations. For example, people who lack access to grocery stores with healthy foods are less likely to have good nutrition.This increases their risk of health conditions such as heart disease, diabetes, and obesity, and even lowers life expectancy compared to those who have access to healthy foods. Simply promoting healthy choices won’t eliminate these and other health disparities. Instead, public health organizations and their partners in sectors like education, transportation, and housing must take action to improve the conditions in people’s environments. That’s why Healthy People 2030 has placed a greater and overarching focus on SDOH.
One of Healthy People 2030’s five overarching goals is specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” This directly aligns with our goals as a healthcare company! A reminder of our mission statement: “We’re reimagining how we deliver and pay for health care.”
apree health has created the first combined, tech-enabled navigation platform and primary care model delivering value-based care. We’re uniting the richest data with powerful technology and the most advanced primary care model available today to provide people with an exceptional experience, better access to information and services, and a lower total cost of care. We are prepared to spearhead the implementation of impactful changes in Social Determinants of Health.
By addressing health inequities – such as poverty, lack of education, and discrimination – we can create a lasting, positive effect on the overall well-being and quality of life for the individuals and communities we serve. This comprehensive approach will lead to improved health outcomes, reduced healthcare costs, and a more equitable healthcare system for all.
apree’s Health Risk Assessments
In December 2024, the apree Registered Nurse Care Guide team initiated a program aimed at addressing a range of critical healthcare needs highlighted within our NCQA Certified Health Assessments (HA). The HA is an assessment we use to help provide personalized care for our members. The health assessment is completed annually by Castlight members and covers areas like mental well-being, sleep, nutrition, financial health, safety, and preventative care.
Recognizing the interconnectedness of physical and mental well-being, the team proactively partnered with our behavioral health clinical services team to revamp our HA with an inclusion on SDOH focused questions such as “In the past 12 months have you had trouble paying for basics like food; housing; medical care and/or heating?”, “Are you worried or concerned that in the next two months you may not have stable housing that you own, rent or stay in as part of a household?”, “Do problems affording childcare make it difficult for you to work or study?” and more. This collaboration not only resulted in the addition of SDOH screening factors into the HRA, but a development of specialized scripts and protocols designed to facilitate effective outreach and support for members dealing with sensitive issues such as suicidal ideation, domestic violence, and other challenges rooted in Social Determinants of Health.
Through their dedicated efforts and strategic interventions, the nursing team has successfully reached and provided services to over 3600 members in less than two months of launching. We are tackling these challenges head-on through a multifaceted approach. This includes:
- Mental and Emotional Well-being: Connecting members to Employee Assistance Programs (EAPs) and a wider network of therapy resources to address mental health concerns.
- Social Support and Basic Needs: Partnering with community organizations to connect members with food banks, housing assistance programs, and other social services to address food insecurity and housing instability.
- Crisis Intervention: Providing immediate access to hotlines and crisis intervention services for members experiencing domestic violence or suicidal thoughts.
- Primary Care Access and Continuity: Ensuring that every member has a primary care provider who is a good fit for their needs, and assisting them in establishing a strong patient-provider relationship.
Through comprehensive strategies, we aim to enhance members’ overall health and well-being, empowering them to live their healthiest lives. By identifying and addressing previously unmet needs, we have successfully implemented impactful changes through proactive measures and strategic resource allocation, significantly improving members’ well-being and quality of life.
One member’s experience
A recent example that highlights the value of our work is satisfaction feedback we received from a member. The member gave us a satisfaction score of 10 out of 10 and expressed immense gratitude for our assistance. After assessing their situation with suicide ideation and domestic violence we jumped in to help in scheduling an appointment with both a therapist from the member’s Employee Assistance Program and a new primary care provider. The member wrote:
“The RN Care Guide was completely understanding of my situation. She helped me much more than I would have expected in a very difficult time. She’s an angel!”
The Health Risk Assessments work has led to many positive outcomes, and this is just one example.
