When Social Factors Stymie Good Health

What are the most common SDOH you see among employed populations?

The most frequent are housing instability, food insecurity, lack of access to transportation, and personal ones like interpersonal victimization that falls into the health-related social needs bucket. What’s really important to know about many of these is that they are not static conditions; they’re not like high blood pressure, where once you have it, you probably have it your whole life. These other conditions can come and go in people’s lives. So, we work with primarily [healthcare] provider customers, and some payers, to have periodic touchpoints to survey for the presence of these risk factors and then have tools in place to do something about them.

How do you determine what SDOH are likely present in a particular patient population?

One is predictive analytics. We work with partners who can create a score based on residential location, because in certain pockets of some communities there are higher rates of food insecurity, for example. The second piece is when a patient is in a healthcare setting. We can deploy questionnaires through text messaging and other ways to collect information from the person in real time. What’s interesting about that is, while many practices ask these questions in the exam room, the rate that people disclose these needs is higher when you’re not asking them face-to-face. We should be actively pinging people to ask them where there may be better disclosure, and it meets them where they are. Then, when they are in the office, SDOH should be a part of the conversation when a provider’s putting together a care plan.

How do the major SDOH impact people’s health?

Social determinants of health can significantly affect health outcomes and a person’s ability to consistently follow care plans. Housing instability and behavioral health challenges can reduce engagement with preventive care and treatment adherence. In many cases, these non-clinical factors are major contributors to avoidable utilization, worsening disease progression, and higher long-term healthcare costs.

Making a clinically appropriate care plan is really only the first step in getting a patient to a better place in their health. As soon as almost everyone walks out the door of my office, they’re not primarily a patient anymore. They’re a mother or father, they’re a caregiver, they are someone who has basic needs that might not be met in their day-to-day life. When doctors make care plans, we assume patients have the bandwidth to act on it, and when they don’t, everybody is surprised. But if we’d done the work, we might understand they don’t live near a pharmacy and don’t have a car, or the $20 out-of-pocket cost is burdensome or prohibitive to them. All those things are important to discover before the patient walks out the door, or else the care plan will fall apart.

Also, food insecurity will impact health through poor nutrition and because of the trade-offs individuals make between adequate nutrition and out-of-pocket medical costs. This is one of the most common, and it’s a great example of one that comes and goes month to month depending on a household’s budget. If you’ve got a family risk, there may be enough calories coming into the household, but that doesn’t mean that the parents feel like they are able to provide what they want for their children. You can imagine how distracting that is, and how stressful it is for the household. In an ideal world, we could check in with people to make sure they are above some threshold of security. And when they are not, it can be addressed; it’s a commodity and easily obtained and delivered.

How can employers benefit from working with an insurer that tracks SDOH?

Employers can benefit from working with insurers that track SDOH because health plans often have a broader longitudinal view of healthcare utilization, risk, and barriers to care across various healthcare providers That connected visibility can help employers identify rising-risk populations earlier, improve care navigation, and support more proactive intervention strategies that reduce avoidable utilization and long-term costs. While the evidence base continues to evolve, research increasingly shows that targeted SDOH interventions can improve engagement, chronic disease management, and healthcare utilization patterns, particularly when organizations can coordinate data, navigation, and community resources.

Many employers may not know how to tackle SDOH in the workplace or think their employee assistance programs (EAPs) manage these issues. Are EAPs sufficient?

Employee assistance programs play an important role, particularly around mental health and short-term support services. However, many employers overestimate their EAP’s ability to comprehensively address broader SDOH challenges and underestimate the value of integrating social support with the medical plan.

Traditional EAPs tend to be reactive and episodic, meaning employees typically engage only after a problem has already escalated. EAPs also require employees to come forward to the employer and disclose needs, leading to historically low utilization rates. Many EAPs also operate separately from healthcare benefits, care management, navigation, and community resource ecosystems, which can limit coordination and long-term follow-through.

For example, an employee experiencing financial stress, food insecurity, transportation barriers, and anxiety may have access to an EAP counselor. But that alone may not help them navigate healthcare benefits, connect with local food assistance programs, arrange transportation to appointments, or manage chronic disease effectively over time. Increasingly, employers are recognizing that addressing SDOH requires a more connected approach that integrates navigation, data, care coordination, and community resources rather than relying solely on stand-alone point solutions. The goal is to embed EAPs within a broader, more coordinated support ecosystem that helps employees access the right resources more easily and earlier.

How does Arcadia work with commercial payers?

Arcadia helps payers create a complete longitudinal view of members by aggregating fragmented clinical, claims, pharmacy, behavioral, and social data into a unified patient record. When health plans have a deeper understanding of the factors influencing a member’s health—including SDOH data, care patterns, and patient-reported information—they are better positioned to identify rising risk earlier, support more proactive intervention, and improve care coordination.

Commercial payers are also seeking greater visibility into provider performance, network effectiveness, and population health trends to optimize care delivery strategies, strengthen provider collaboration, and make more informed operational and network decisions. Arcadia delivers provider performance insights and benchmarks.

Are there types of employers for whom tracking SDOH is most beneficial?

Tracking SDOH can be particularly beneficial for employers managing large, geographically diverse or higher-risk populations, especially those with significant chronic disease burden or workforce [healthcare] access challenges. Industries with frontline, hourly, lower-wage, rural, or highly distributed workforces may see greater impact because employees are more likely to face SDOH barriers including limited provider availability.

That said, social risk factors affect virtually every population to some degree, and many employers are increasingly recognizing that workforce engagement and their health are closely connected. The organizations seeing the most value are typically those focused on proactive population health strategies, care navigation, and long-term cost management rather than simply administering benefits.

What suggestions do you have for employers that want to better help manage their workforce’s SDOH challenges?

Employers do not need to become experts in social services, but these resources are essential in creating visible and stigma-free pathways for employees to seek support. Employers interested in addressing SDOH should start by focusing on support, navigation, and access rather than collecting large amounts of sensitive employee information directly from workers. A practical first step is to use aggregated claims, pharmacy, absenteeism, and utilization data to identify broad population-level patterns that may signal barriers to care, such as high emergency department utilization, low engagement in preventive care, or gaps in chronic disease management. Many organizations begin by partnering with local provider organizations, health plans, navigation vendors, or community resource platforms that can help employees more easily access things like transportation assistance, food support, behavioral health services, childcare resources, or financial wellness programs.

For example, if an employer notices high rates of missed follow-up care among employees managing diabetes, the underlying issue may not be clinical at all. Employees may struggle with food insecurity or have difficulty navigating benefits and scheduling appointments around work and caregiving responsibilities. The employer could work with a health plan or navigation partner to offer voluntary outreach, digital navigation tools, transportation support, or referrals to local food and community assistance programs. Technology can also help organizations understand whether employees were successfully connected with those resources through closed-loop referral systems while still maintaining appropriate privacy boundaries.

Insurers will potentially have access to the data and use it to help identify patients that need special attention. In certain communities, if there is a provider the employer can partner with, that can be a great part of their conversation—they are good at clinical services, but what else can they do for these other needs? Do they have existing relationships with community-based organizations that the employer could expand? That also puts the employer in a position to support these community-based organizations.