“The evidence is clear,” said CMS Administrator Seema Verma, “social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s wellbeing.”


Striving for health equity is a passion of our team, and the CMS announcement in January that issues guidance on strategies to address social determinants of health opens new opportunities for Health Plans to improve population health outcomes.


We want to share a specific way this new guidance has impacted our ability to help the members of one of our clients, but first, let’s discuss more about social determinants of health.


What are Social Determinants of Health?


Social determinants of health are conditions in a person’s environment that are outside the typical healthcare system but influence a person’s health and access to health care. These can include factors such as socioeconomic status, education, neighborhood, physical environment, employment, behavioral health, social support networks, and public safety.


These factors present barriers that can increase health care utilization and cost, worsen health outcomes, and widen health disparities between populations.


It’s easiest to understand through an example.


Common health advice would say “Eat healthy food to live a healthy life.” Seems simple enough – even though most of us know it’s not always easy, even when we have endless access to what we need to live a healthy life.


A person’s individual circumstances can complicate the ability to lead a healthy life. Growing up in a poor education system with limited access to a good job can lead to living in a poor neighborhood with a food desert – an area with limited access to healthy and affordable grocery and dining options. That person is less likely to have good nutrition which can lead to diseases like heart disease, diabetes, and obesity. That person would also have less access to affordable health care options which means the disease isn’t managed properly.


All along this person’s journey are opportunities to address social determinants before they become unhealthy to the point of lowered life expectancy. But in the current state, the Health Plan is managing costly diseases instead of preventing them.


Social Determinants of Health and COVID-19


These social determinants have been exasperated by the COVID-19 pandemic revealing the need for long overdue systemic change. BMJ released a study on the impact of COVID-19 on social determinants of health and provided numerous ways the pandemic has only caused a greater divide in health equity, such as precarious and adverse working conditions, growing economic disparities, and anti-democratic political processes and institutions.


The American Medical Association House of Delegates adopted 5 policies to address the impact of COVID-19 on social determinants of health:


    1. The AMA, recognizing that social determinants of health encompass more than health care, encourage new and continued partnerships among all levels of government, the private sector, philanthropic organizations, and community- and faith-based organizations to address non-medical, yet critical health needs and the underlying social determinants of health.


    1. The AMA support continued efforts by public and private health plans to address social determinants of health in health insurance benefit designs.


    1. The AMA encourage public and private health plans to examine implicit bias and the role of racism and social determinants of health, including through such mechanisms as professional development and other training.


    1. The AMA support mechanisms, including the establishment of incentives, to improve the acquisition of data related to social determinants of health. With the gaps and inconsistencies in data pertaining to social determinants of health, policy makers are without the research needed to determine how best to integrate and finance nonmedical services as part of health insurance benefit design.


    1. The AMA encourage pilot programs to test the impacts of addressing certain nonmedical, yet critical health needs, for which sufficient data and evidence are not available, on health outcomes and health care costs.


It can be overwhelming to know how to address all these issues, but with collective guidance and a focused approach, companies like Shearwater Health and the clients we work with have an opportunity to make an impact.


The Impact of One of Our Social Determinants of Health Programs


When we work with Health Plans or Health Plan Partners on programs to address social determinants of health, our vision is to identify and close gaps to expand the reach and impact of their clinical teams. By removing barriers, we get healthier members, and healthier members lead to decreased cost for everyone involved.


Most recently, we worked with a post-acute benefits management company focused on delivering innovative home and community-based product offerings.


Shearwater Nurses already review cases, and with the new CMS guidance, the client wanted to identify high risk member cases for in-person follow-up. Shearwater used criteria and clinical knowledge to identify members that were facing large gaps due to social determinants of health. By identifying the specific barriers of members, the client is better able to address their needs. While it requires clinical judgment to put the pieces together, the data in the charts provides opportunities to automate workflows for more efficient case referrals.


But it’s not just about the numbers for us. We’ve been impacted by the humans behind the cases.


Here are a few of the barriers identified with real people (fictional names for privacy reasons):


Member 1 CindyMEMBER 1 – “Cindy”

  • Inadequate dental support which causes difficulty chewing that affects diet
  • Multiple ER visits in last 6 months
  • Decline in emotional, mental, and behavioral status in last 3 months


Member 2 JosephineMEMBER 2 – “Josephine”

  • Transportation barriers with only a multi-wheeled walker
  • Lives alone with inadequate care support
  • Unable to take meds without another person
  • Multiple issues of non-compliance ranging from clutter/soiled living area to ignoring medical, diet, and exercise advice leading to poor health outcomes


Member 3 BarryMEMBER 3 – “Barry”

  • Homebound with unsuitable living conditions that lead to frequent falls
  • Cognitive impairment that leads to confusion when given instructions and needs assistance taking medications
  • Available assistance during the day only and caregivers need additional training
  • Multiple hospitalizations in last 6 months


Real humans with real barriers to adequate health care. Identifying these issues that lead to non-compliance can give Health Plans the insight needed to address social determinants.


This was just one pilot program where we see potential for scale across Health Plans. With a dedicated team of clinicians focused on removing barriers, we can get a step closer to health equity. Working with Shearwater means a global clinical team is impacting local population health outcomes that improve your members’ wellbeing and overall community health.


Jennifer Robertson, BSN, RN

Vice President Payer Services, Clinical Operations