Delivering effective care to high-risk populations is challenging. As the costliest patients to treat, at-risk patients—typically those with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions—strain the entire healthcare system, requiring treatment from many different providers and a large investment of time and resources. If patients are unemployed, uninsured, or uneducated, the impact of their conditions is magnified. These forces result in an epidemic of poor health in our disadvantaged communities.
While we know that outcomes can be materially impacted by non-clinical factors like social determinants of health, the industry’s strong focus on medical factors have long pushed social determinants to the backseat. It is clear that population health management is most effective when it is comprehensive and community-based, extending beyond the walls of a single care establishment to encompass all relevant services, including medical, behavioral, and socioeconomic factors. But what will truly make a difference to patients is being able to prescribe how to address the social determinants in a normalized manner that will consistently improve patient outcomes.