Social Drivers of Health (SDOH), also referred to as Social Determinants of Health, are gaining traction among multiple payers, making now the time for organizations to act. Those embracing value-based care are already seeing measurable outcomes that benefit both patients and the bottom line. Geisinger Health’s Fresh Food Farmacy, for example, reduced hospital admissions by 75% and cut emergency department visits by 30% among diabetic patients. The University of Pittsburg Medical Center (UPMC) Housing First program saved $6,384 per member each year. The message is clear: addressing SDOH is not just good for patients, it’s a smart strategy for sustainable care.
Executives across Accountable Care Organizations (ACOs) increasingly recognize that addressing SDOH plays a critical role in closing care gaps and ensuring financial sustainability. As participants in the Medicare Shared Savings Program (MSSP) and ACO REACH face mounting pressure to meet social needs, they now view SDOH interventions as essential to achieving meaningful, long-term cost savings.
Healthcare organizations are moving beyond basic referrals and are now forming structured partnerships with community-based organizations (CBOs). In North Carolina, NCCARE360 connects individuals to vital community resources through a statewide coordinated care network. Programs like Healthy People, Healthy Carolina tackle chronic conditions using community-driven, social approaches that deliver real impact.
CHESS has partnered with Piedmont Triad Regional Council to explore referring patients with social needs to community health workers. Shared data—critical to this long-term partnership—closes the referral loop and ensures transparency between clinical and community settings. This cohesion benefits patients, providers, and health systems alike. By extending the care team’s reach without requiring major infrastructure changes, partnerships like this drive meaningful progress in addressing Social Drivers of Health.
For many organizations, especially those with limited resources, addressing social needs can feel overwhelming. A practical first step is to implement a screening tool as part of an SDOH strategy. Many ACOs have developed technology solutions that embed SDOH screening directly into EHR workflows, using validated tools like the NC SDOH tool, PRAPARE, or the ACH-HRSN. These integrations automate referrals based on screening results, deliver timely updates on referral status across care settings, and generate analytics to identify community-wide gaps.
To successfully implement SDOH initiatives, organizations must embrace new, innovative approaches. CHESS drives progress by engaging C-suite executive champions who highlight the strategic importance of SDOH. This leadership fosters collaboration and ensures that the health team, care team, and community all have a voice in decision-making.
SDOH doesn’t stand alone as a project or priority—it functions as a core component of a successful value-based care strategy. Staying focused on success, even amid competing priorities in healthcare, is key for driving sustained transformation.
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