3 Steps to identify & address social determinants of health

From transportation options to affording prescriptions, many members avoid or forego care due to social determinants of health. Doing so can lead to costly and long-term impacts to members’ health outcomes.

In the years following the COVID-19 pandemic, many health plans implemented digital solutions to improve member engagement and outreach. Despite having these resources, health plans still face obstacles in identifying health barriers. To proactively address social determinants of health, your health plan can leverage digital solutions to uncover care gaps and deliver personalized support.

Based on experiences with our health plan customers, we’re sharing our three-step strategy for using technology to address social determinants of health:

1. Uncover barriers to health and care access

2. Alert care teams to members’ health barriers

3. Guide the member to the right resource or benefit

Step 1: Uncover barriers to health and care access

Care teams may find it challenging to reach, onboard, and engage high-risk members through traditional outreach. Many members don’t have a landline or “home phone”, may frequently change addresses, or be unable to answer calls during regular business hours. Digital health management platforms can make it easier for your organization to capture day-to-day information on member needs and behavior that you wouldn’t have access to otherwise. Digital health tools can make it easier to uncover and address social determinants of health through features like:

  • Asynchronous communication channels that allow members to respond on their own time
  • Mobile surveys and assessments that can uncover health barriers due to social determinants
  • Relevant and accessible health education and resources that improve member trust

Step 2: Alert care teams to members’ health barriers

A digital health management platform can generate unique insights and encourage more frequent touchpoints between care teams and members. To be most effective, care managers need access to the most important member information as soon as possible. The Wellframe dashboard alerts care managers to survey responses or other member actions that indicate a care gap or social determinant of health.

Plus, features like 1:1 secure messaging make it easier for members to reach out to care managers and build trusting relationships. Some members are more willing to share information in a message than in person or over the phone and prefer to write a thought-out response.

Digital platforms help keep care managers informed of barriers patients have identified and let them get to know patients so that they can help them find personalized solutions. For example, if a member shares that they’re unable to access certain healthcare services, care teams should have enough background on that individual to direct them to accessible resources that fit their specific needs.

The digitally-enabled workflow

Step 3: Guide the member to the right resource or benefit

Like many health plans, your organization may be holding off on expanding your staff or care teams. So how can your health plan address a broader range of member needs with the resources you have available?

Digital health platforms can help care teams seamlessly triage members based on their needs and connect them to the right services. With Wellframe, care managers can enroll members in digital care programs to make sure they receive consistent support and education based on their diagnoses or conditions. Secure messaging also makes it easier for care teams to get members in contact with specialists as well as non-clinical staff.

By streamlining these resources through a digital health platform, care managers can follow up with other staff members to confirm they helped address members’ health barriers. Care managers can also provide ongoing follow-up and support to members and ensure they have the guidance they need.

Key takeaways

Identify and address social determinants of health more easily with digital health solutions like Wellframe. Digital platforms can help your care teams eliminate health barriers and improve member outcomes by uncovering key member insights earlier. Make sure your organization has a digital health management strategy that can help you address these barriers.


Helping your members address social determinants of health can improve outcomes and lower costs. Doing so can also help boost your Star ratings by delivering timely, effective care and increasing member experience.

Read our “Star ratings guide: Three steps to improved scores” to see the successful strategies other health plans are using.