A little over two years ago we embarked on a journey fueled by research data and an innate desire to help change the world of healthcare. It puzzled us that so much care is provided by family, friends and the community in general, but so few tools and services were available to support this effort. It also puzzled us that so little professional help is available to support and coordinate those valuable efforts. So much more could be done to alleviate pain, suffering and cost if this field was just developed more.

It seemed incomprehensible that study after study, case after case, the evidence clearly shows that social determinants are key drivers of health, yet, few if any comprehensive efforts and scalable solutions were available. In this blog we outline some thoughts and research on the subjects, and share some lessons learned from being actively engaged in providing these largely non-clinical services that remove barriers for our customers and patients:

1. The facts clearly show: Social Determinants Based Barriers Matter

Studies have been plentiful for many years demonstrating that longevity, quality of life and healthcare costs are highly correlated to Social, Environmental and Behavioral factors. McGinnis Et Al showed that only about 20% of health is determined by health care, while another 20% is driven by genetics, and a monstrous 60% is due to the social, environmental and behavioral factors. A study by the Henry Ford Health System in 2014 showed that hospital costs were 24% higher for socially isolated individuals; 84% of health care spending is attributed to 50% of the non-institutionalized population that has one or more chronic conditions, and 17% of patients with chronic conditions receive conflicting care information from providers. Add to these facts that 33% to 69% of hospital admissions in the US are due to poor medication adherence (Osterberg and Blaschke), which is often due to habitual, infrastructure or economic issues, and a picture emerges that an isolated focus on clinical care plans without social determinants consideration will not lead to population health management success.

Unfortunately, little has been done to comprehensively address this, with few exceptions, for two key reasons:

  • The economic incentives have not been aligned to pay for services that address non-clinical issues and barriers. To this day, while we are moving to value based care, payment for services that prevent disease development or escalation are few and far between. That said, those organizations that ‘own the risk’, be they employers or health plans, are beginning to invest in support structures to address these issues, because the return is so significant. The challenge, however, is that only the most brittle, high risk individuals receive this level of attention in most cases, as the traditional services models carry a price tag that is too high for what is now considered the rising risk population.
  • Addressing these issues can be very challenging, especially for organizations and systems that have never really had to make resolving these issues a core competency of what they do. Ultimately, this area is a distinctly different domain requiring unique expertise.

2. There is a proven success formula to addressing these types of barriers

When we talk about social determinants, we really mean barriers. Real life barriers. The barriers one has to overcome to remain well, and to ensure that medical conditions are either not developed, or if they exist already, that they don’t escalate. Often these are things like:

  • Needing to change habits that have been developed over decades
  • Not having access to transportation or proper nutrition
  • Needing to maneuver a very complex system of forms and authorizations to gain access to provider, payer or community based services
  • Not being part of an affordable monitoring system that can intervene in real time
  • Social pressures that perpetuate counterproductive behaviors

To add to these already significant issues, clinical care plans are often overly lengthy, confusing and at times conflicting. Many patients simply give up and return to their unhealthy ways. A complex matter indeed, and not easy to resolve, or is it?

In reviewing successful social determinants, change management and social gap closure programs, there is a common thread that can be found across all successful initiatives:

  • In each case the first step is to establish a trusted relationship with the individual that can benefit from the support. Only through this genuine and trusted relationship can we learn the true issues preventing an individual’s success and the personal motivations that allow us to help change the game.
  • Initially, the barriers will be overwhelming, many individuals are simply stuck in their situation. The trusted individual can not only help eliminate these barriers, but deepen the relationship and further support a change to better habits by providing support.
  • Habits and patterns must first be changed, repetitively, for the mind to follow (this is 180 degrees off current approaches, where we attempt to provide information, thinking the rational mind will change habits, which, as it turns out, does not work well). This requires a realistic approach to care plans, and a realization that habit changing is far more important than perfection regarding the plan elements, especially initially. A perfect plan not executed is less valuable than a good plan followed.
  • Third, new ways of thinking, and corresponding actions are developed over time, helplessness turns to action, and isolation turns to being part of a community of giving and receiving.

3. Social Determinant Care Support Enables Clinical Care Plans

Care plans today are often viewed as a combination of physician orders and instructions, as well as nursing care plans. They have a clinical focus and establish, clinically, what is believed to be the best plan of action for the patient. They are presented, usually, in paper format, to the individual, to take home, and then to execute to. Several issues can arise with this model.


  1. The care plans are generic and represent “best practice”, which in many ways is a good thing. The issue is, the care plan often does not fit the habitual reality of the individual, and if all too complex and burdensome, will have only limited execution success. The lesson learned is, care plans have to fit the habitual profile of the person the care plan is designed for. Forming habits should also be a key consideration in care plans, then we can add complexity after key base habits are firmly established.
  2. There is a world of non-clinical issues that prevent the clinical care plan if the choice is to buy food, or to buy medication, the allocation of funds will go to food. If an appointment is made, but the individual does not have access to transportation, the appointment will be missed. If the individual cannot sleep because their mattress is lumpy, the fall risk from being groggy increases, and odds of re-admission go up.

The solution? Clinical and medical care plans need to be enabled through social determinants care plans and support. These thoughts and approaches are not at odds with each other, but rather they supplemental one another. The social care plan and personalized human help improves the odds of the clinical care plan having efficacy by orders of magnitude. It is like putting the turbo charges onto the clinical care plan.

4. Getting Practical – Lessons Learned & How To Make Forward Progress

Being a company of mostly engineers and techies, we did what all technical folks would do, we started building an app. We spent about one and a half years creating the ‘Facebook meets wellness’ technology where wellness “To Do” plans can be created, personal and community relationships can be built, rides and meals can be requested, medication reminders can be sent, biometrics shared, and so on. Build it and they will come, except, that is not how it works. Then about one year ago we added to our thought processes, and awakened the amateur social worker in us. What if we created a service that provides individuals with a personal ‘concierge’? What if we went to the places where individuals may need the support of scheduling rides, help fill prescriptions, arrange meal delivery, or make doctor appointments so they can be seen in time before something bad happens, and meet each person. We brought physicians, nurse practitioners, social workers and assistants into the program. A service model was created, with the technology being an enabler to provide the help that can make a difference to wellness. Recently, we have partnered with independent and assisted living facilities to help those residents wanting some support regarding non-clinical barriers. We start our relationship with a face to face meeting, where we discuss each individual’s comprehensive situation. A customized plan is created for each person, with consideration of not only clinical, but all other realities. We then touch base in real time, or periodically, and see what barriers we can help remove.

In the end, we had mattresses delivered through community resources, made appointments at critical times, found a lost wallet with insurance cards needed to gain access to care, secured pharmaceutical program assistance to ensure the patients had the best suited medications available, and removed many other barriers. We have worked hand-in-hand with the primary care physicians and made sure we are viewed as a help and not a hindrance by the clinical community. And, best of all, it is all done as part of an existing Medicare program providing the service to many Medicare beneficiaries. It is a small beginning, but we firmly believe it is one of the seeds that is proving to make a big difference.

5. The Only Question Remains: Will You Join the Movement?

Everyone in healthcare is busy re-tooling their world to match the changing realities of value based care. It is easy to get overwhelmed, and not have the resourcing to work on something that seems ‘far out there’. We agree. That said, we continue to expand this concept with those organizations that are ready to embark on the journey of enhancing care beyond the purely medical definition, and help build a practical and economic solution to address this next layer of healthcare. For more information about joining the movement, visit us at healthcare-consulting.org.

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