Beyond Screening: Turning Social Determinants of Health (SDoH) into Actionable Solutions
📌 This article is part of my "5 Healthcare Trends to Watch and Act On" series.
In this series, I’m breaking down five key healthcare trends shaping 2025—why they matter, how they’re impacting the industry, and what healthcare leaders should do next.
💡 Explore the Full Series:
🏠 Overview: 5 Healthcare Trends to Watch and Act-On
1️⃣ Trend 1: Data Security Becomes a Competitive Advantage
2️⃣ Trend 2: Data Interoperability Becomes the Backbone of Healthcare
3️⃣ Trend 3: Advanced Risk Stratification and Predictive Analytics
4️⃣ Trend 4: Addressing Health Equity Through Social Determinants of Health (You’re here)
5️⃣ Trend 5: Value-Based Care (VBC) Drives Innovation
Healthcare is shifting from reactive care to proactive intervention, and addressing Social Determinants of Health (SDoH) is a critical component of this transformation. While health plans and providers have long recognized the role that social, economic, and environmental factors play in health outcomes, efforts to integrate SDoH into care models have been fragmented and slow to scale. Now, as reimbursement models evolve and the need for cost-effective, outcome-driven care intensifies, organizations must rethink how they engage with and leverage SDoH solutions.
Current approaches to SDoH often focus on screening rather than intervention. While identifying social needs is important, the real challenge lies in closing the loop and ensuring that identified needs translate into actionable solutions. Health plans, health tech vendors, and investors must move beyond static data collection and adopt strategies that embed SDoH insights into real-time care management, predictive analytics, and value-based reimbursement models. Those that do will be positioned as leaders in the next era of healthcare transformation.
Challenges in Scaling SDoH Solutions
Despite widespread acknowledgment of the importance of SDoH, significant barriers remain. Health plans, providers, and vendors operate with siloed data sources that do not communicate effectively, making it difficult to track and address social needs comprehensively. Much like the interoperability crisis plaguing healthcare, SDoH initiatives suffer from fragmented and siloed data, making it difficult for health plans and providers to take meaningful action. Interoperability’s real-world impact requires moving beyond data collection and evolving to seamless integration, active translation, and the ability to drive action across care teams and social service organizations.
A major challenge is that much of the SDoH data needed for effective intervention is buried within unstructured clinical documentation, making it difficult to extract and apply at scale. Advances in generative AI are changing this by surfacing social risk factors from complex visit notes, helping organizations identify and act on social determinants with greater precision. By leveraging these AI-driven insights, health plans and providers can move beyond passive data collection toward proactive, real-time intervention strategies that improve outcomes and reduce costs.
Many SDoH tools operate independently rather than embedding directly into care coordination and case management platforms. Without clear integration into existing workflows, social interventions often remain separate from broader care strategies, reducing their effectiveness. Additionally, the financial benefits of SDoH interventions often take time to materialize, creating hesitancy among health plans and investors who need to see immediate ROI.
Some organizations may view health equity as a lower priority amid shifting policy landscapes, but the financial reality remains unchanged. Unaddressed social risk factors lead to increased emergency visits, hospitalizations, and higher overall costs for health plans. Ignoring these challenges does not make them go away. It only shifts the financial burden to more expensive care settings.
Provider engagement also remains inconsistent. Without financial incentives or seamless workflows, many providers struggle to collect and act on SDoH data. This lack of alignment between incentives, technology, and care delivery creates friction that slows adoption and limits the potential impact of SDoH-focused interventions.
What Needs to Change
The potential for SDoH to drive meaningful health improvements is undeniable, but achieving impact requires a fundamental shift in how solutions are designed, implemented, and evaluated. Health plans must align SDoH initiatives with broader care management strategies, ensuring that social interventions lead to measurable improvements in health outcomes. Vendors need to move beyond one-off data collection tools and build solutions that drive action and accountability. Investors should focus on scalable, revenue-generating models that offer sustainable, long-term value rather than short-term grant-funded initiatives.
Health Tech Vendors
Health tech vendors must ensure SDoH insights are embedded directly into care management platforms so social risk factors are not just identified but acted upon, triggering automated workflows that make it easier for care teams to intervene without added administrative burden.
To stand out, vendors should:
Embed SDoH insights directly into care management platforms to ensure social risk factors are not just identified but acted upon. SDoH data should trigger automated workflows, making it easier for care teams to intervene without added administrative burden.
Close the referral loop by ensuring that flagged social needs translate into completed interventions. Vendors must provide tracking mechanisms and outcome reporting to measure the effectiveness of referrals and ensure members receive the support they need.
Demonstrate clear, measurable ROI by showing how interventions lead to reduced hospitalizations, improved Star Ratings, and lower total cost of care. Vendors that quantify financial and clinical outcomes will be more attractive to buyers and partners.
Vendors that eliminate workflow friction, prove financial impact, and integrate seamlessly into existing infrastructure will win over health plans and providers. Those who move beyond static data collection and enable real-world action will define the next wave of SDoH innovation.
Health Plans
Health plans recognize the importance of addressing social risk factors but often struggle with scaling financially sustainable solutions. Many rely on pilot programs or grant-funded initiatives that fail to generate long-term impact. To lead in this space, health plans must embed SDoH into their core care management and risk stratification strategies.
To stay ahead, health plans should:
Integrate SDoH into value-based care models, ensuring that social risk factors are tied to reimbursement frameworks, quality measures, and health outcomes. Aligning financial incentives with social interventions will drive long-term adoption.
Move from screening to intervention by embedding SDoH insights into existing clinical workflows. Identifying social risks is only the first step, and health plans must ensure that flagged needs translate into concrete actions through care teams, community partnerships, or financial assistance.
Leverage AI-driven predictive analytics to identify at-risk members before social determinants escalate into high-cost medical events. Proactive risk management enables earlier, more cost-effective interventions and reduces avoidable utilization.
Reducing focus on health equity does not eliminate its impact. Members facing social risk factors will continue to drive higher utilization and costs if left unaddressed. Health plans that proactively integrate SDoH into their risk management strategies will not only improve outcomes but also avoid the financial strain of preventable high-cost interventions.
Private Equity & Venture Capital
Investors looking for scalable, high-impact healthcare companies should focus on those that embed SDoH solutions into broader care management strategies. The next wave of healthcare transformation will be driven by companies that seamlessly integrate social determinants into clinical and administrative workflows.
To maximize value, investors should:
Back vendors that bridge the intervention gap, ensuring that SDoH insights translate into real-world action rather than stopping at data collection. Solutions that close this loop will drive stronger adoption and outcomes.
Prioritize interoperability, investing in companies that seamlessly integrate SDoH data with existing EHRs, care management platforms, and payor systems. Fragmented solutions struggle to scale, so investors should focus on platforms designed for seamless integration.
Demand clear revenue models beyond grant funding, ensuring that SDoH solutions are embedded within reimbursement structures, payor contracts, or risk-sharing agreements. Sustainable revenue streams will separate long-term winners from short-lived pilots.
Even as regulatory priorities evolve, the market need for cost-saving interventions remains constant. Investors who back solutions that help health plans reduce avoidable medical expenses and improve member engagement will find long-term value, regardless of broader policy shifts.
The Path Forward
SDoH initiatives are at a turning point. The industry has moved beyond recognizing the importance of social risk factors, but the “actioning” has remained relatively slow due to fragmented data, misaligned incentives, and tools that fail to close the loop between identification and intervention. The organizations that succeed will be those that take decisive steps to embed SDoH solutions into real-time workflows, align them with financial models, and drive measurable health improvements.
Health tech vendors must prioritize seamless integration, enabling care teams to act on SDoH insights without adding administrative burden. Health plans must move past static screening and ensure that social interventions are financially sustainable and clinically impactful. Investors must back companies that turn data into action, ensuring that solutions don’t just analyze social risk but drive meaningful change.
The future of healthcare belongs to those who embrace innovation and evolve beyond data collection into real-world impact. Those who commit to scaling SDoH interventions will not only strengthen their own organizations but will also improve outcomes for the members and communities that need it most.
🔥 If you liked what you’ve read, there’s more where that came from.
This article is part of my "5 Healthcare Trends to Watch and Act On" series, where I break down the biggest shifts shaping 2025. If you want to see all five trends at a glance and dive into the ones that matter most to you, check out the full overview here.
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