Kristin Haluch , 2025-05-06 13:37:00
Recently, I had the privilege of chairing the virtual RISE Bedrock of Healthcare Social Determinants of Health (SDOH) event and attending their national in-person SDOH Conference. SDOH has been a hot topic in healthcare over the last several years, and for good reason. The data is clear: a very small percentage of health outcomes are tied to direct healthcare activities. The non-medical factors, conditions in which people are born, grow, live, and work in, more often than not, impact health outcomes more than the clinical care they receive.
After connecting with SDOH experts, including health plan leaders, community-based organizations (CBOs), providers, and people with lived experiences, a few common themes emerged that deserve deeper reflection:
It’s not always non-compliance – it’s inaccessibility
We need to retire the term “non-compliant” for good. Uncovering the root cause for these gaps in care often shows a maze of barriers, rather than a disinterest in engaging in the care they need.
People do not want to live with chronic diseases or cancer. However, for many, the reality of going to a doctor’s appointment to get a preventative screening or immunization means they miss work. Missing work, on top of the lost wages, means having to find a caregiver for their child or elderly spouse and securing transportation. Their health plan may offer resources to assist, like a free ride to a doctor’s visit, but they either don’t know it exists because accessing their benefits are complex and frustrating or they have two children, and the ride allows them to only take one additional person to the appointment. So, when they don’t go, they’re labeled as “non-compliant”.
Rather than focusing on labels, we must use available data to identify the root causes behind care gaps, like missed appointments, and use these insights to shape programs to remove root cause barriers. One example I was impressed by was the opening of a community center that not only provides transportation but also allows for more than two passengers while offering free childcare during appointments. The rides also include tablets for the patient to access health plan resources during their trip. Barriers are removed and the community health outcomes are improving.
CMS makes it hard for us to collect data we need to address SDOH
We heard multiple times over these two events that the challenge of collecting SDOH data, like Z-codes, is that the Centers for Medicare & Medicaid Services (CMS) doesn’t give us enough spaces to enter them on the claim form. Something as simple as how many boxes are on a form, should not be the barrier providers must face when trying to better understand and serve their patients.
Z-codes allow us to understand the underlying stories and root causes affecting a member’s health that need to be addressed. Having this data and understanding it is critical for us to move SDOH work forward in a meaningful way.
If we want providers and health plans to meet expectations around SDOH interventions, we need procedures that remove friction, not add it.
Trust and psychological safety are the foundation to which you build member engagement upon
It’s no secret that there is a lack of trust between the health care system and its consumers stemming from a systemic set of challenges like changes in network, bills that weren’t expected, lack of access to care, and lack of empathy-based customer service. On top of that, there is an incredible amount of fear right now as we face daily changes to healthcare policies and funding as a country.
We heard stories from speakers at RISE of people who are worried that if they attend their doctor’s appointment, ICE will be called and they will be detained or deported, so they avoid care at all costs. People in the LGBTQ+ community are afraid to share their personal information, in fear that there will be repercussions. Those suffering with substance use disorder are afraid that if they share that information or seek treatment, that their jobs and personal relationships may be put in jeopardy if anyone were to find out.
Healthcare leaders need to be talking about how their organizations can build psychological safety through improved business processes, communication efforts and community support. Grievances and patient survey data are a few places to look to identify trends for what processes or areas of the business are eroding trust with your members/patients.
Organizations that initiate grassroots efforts by spending time in the communities they serve and asking people to share their lived experiences are able to more quickly identify the needs in the community and build programs to address them. If your organization is leveraging community health workers, make sure there is a mechanism for their learnings and findings to reach key decision makers that are responsible for designing programs, benefits and interventions.
We know SDOH interventions work, so let’s trust the data, and fund the programs
There is an extensive body of research on SDOH initiatives that are proven effective, for example giving a low-income pregnant mother access to healthy meals will have a positive impact on her pregnancy outcomes. However, we continue to be asked to prove that these already proven interventions will work and must fight for funding to implement them. With the recent CMS announcement regarding it not approving future federal matching funds for designated state health programs (DSHPs) and designated state investment programs (DSIPs), we face yet another challenge of finding creative ways to provide programs to those who need them the most.
As health plans navigate this challenge, work alongside your community-based organizations to find creative ways to partner. Consider expanding partnerships to include foundation, associations and the faith-based community to fund and continue critical services for your members. Continue to engage with and advocate for policy flexibility with local and state government.
The general consensus from those I connected with at these RISE events was that we aren’t giving up, but we’re tired. A patient advisor and RISE speaker bravely shared that during the conference she lost her SNAP benefits because she missed an appointment scheduled on her behalf without notification. The impact that this will have on her family is unfathomable for most. However, she showed up and shared her story because she knows so many who experience those hardships daily can’t advocate for themselves. This work is hard, and we don’t have all the answers. But because we entered this career in healthcare to be in the service of others, to those who need it the most, we stay the course.
Photo: gmast3r, Getty Images
Kristin Haluch, MHA, is Managing Director at Innsena, a healthcare-focused go-to-market consultancy. She has led initiatives across Medicare, Medicaid, and commercial health plans, and has worked with ACOs, Fortune 500s, and startups. Kristin serves on the Board of Directors at U.S. Hunger, a nonprofit focused on food insecurity and health equity. Her past leadership roles include positions at Optum Health, where she led the Southern California ACO programs, that generated over $14M in Shared Savings over a two-year period. She also contributed to Walmart’s Centers of Excellence program and led the scaling of national networks at Spreemo Health and One Call. She earned her MHA from Ohio University.
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