More Thinking and Insights

SDoH Outlook for Chronic Conditions

April 07, 2021  |  Guidance


Yogin Shroff, Senior Partner and Chief Operating Officer

Food insecurity, housing insecurity, transportation, and overall limited access to care are leading indicators for chronic conditions and diseases, invariably triggering poor health outcomes.

Comprehensive diabetes care and blood pressure

Comprehensive Diabetes Care (CDC) measures typically hold the highest weight of all clinical measures within the CMS Stars structure. Low national performance and overall health risk are two of the chief methodologies behind the weighting of these measures -- ensuring that healthcare organizations are prioritizing high quality and cost-effective care for members suffering from chronic conditions. While completing eye exams and monitoring nephropathy are key measure sets for the diabetic population, so too is the member's ability to maintain in-control blood pressure and blood sugar level.

Commonly, poor health outcomes across the diabetes and hypertension measures are borne out of social determinants of health risk factors. Individuals suffering from social isolation, housing insecurity, and general low income tend to face health complications that can spike blood pressure to uncontrollable levels. Similarly, hemoglobin A1c levels are directly correlated with both food insecurity and food illiteracy. It is necessary for individuals to not only have access to healthy food alternatives, but to also understand what is considered a healthy diet. Without proper engagement and education from health plans and provider systems, diabetic members face high risk of health deterioration, leading to increased financial strain on the healthcare system. Even annual dilated eye exams and kidney disease tests are hampered by SDoH risk factors such as limited access to care, implicit bias, and overall health inequities. Hence, the more healthcare organizations strive to resolve the underlying reasons for social determinants of health, the more successful their quality improvement initiatives will be.

Ready to learn more? We'd love to hear from you.