Population Health

How can ACH's address the impact of social determinants on population health?

Abhinav Shashank
Tue 25 August 2020
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Over the years, researchers have strengthened the idea that the conditions in which we live and work enormously affect our health and well-being. These conditions broadly categorized as Social Determinants of Health (SDoH) can, directly and indirectly, shape physical and behavioral health while individuals can do little or nothing to control these factors. These determinants include the most basic elements of community and surroundings, such as education, income, living and working conditions, availability of transportation, and environmental factors (e.g., lead paint, polluted air and water, dangerous neighborhoods, and the lack of outlets for physical activity). 

Addressing these challenges in the healthcare continuum usually revolves around connecting patients with social and educational services to meet specific needs. Accountable communities of health (ACHs) are a multi-sector alliance that includes multiple payers, healthcare systems, and providers that can improve the impact of these factors on communities. However, communication and collaboration among various agencies, primary care and behavioral healthcare providers are often limited, disjointed, or non-existent. Such situations can impede care quality and drive up costs.

Recognizing and addressing the role of social determinants

Commonly cited statistics elucidate that clinical care influences a mere ten to twenty percent of a patient’s outcomes, while social determinants of health impact the remainder. The impact of this can be seen in cases such as one where a patient cannot adhere to his/her hypertension care plan because of the expensive medication he/she has to buy every month. In such cases, the outcomes will surely suffer. Similarly, outcomes will not improve for an obese patient, if he/she cannot afford healthy food options or get to a grocery store miles away from home. 

Providers, as well as community experts, need to recognize the social adversities and the impact that they are making on population health in that region. Screening becomes an essential part of the process for this to happen. Providers and community health stakeholders can screen this relevant information in multiple ways. May it be paper questionnaires before a patient sees the clinician, conversations while discussing treatment options, or community data collected digitally that can give context to where a patient lives and works, the importance of this information is unparalleled.  

Integrating social determinants into workflows 

Regardless of how it is collected, this information needs to be incorporated into a patient’s medical record. Providers and other stakeholders can then use it for clinical decision-making and help care teams streamline care for patients. A patient’s previous medical diagnosis data is available to the providers, which ensures the quality of care. Similarly, the easy availability of data relevant to social determinants will personalize treatment options and the care delivery to boost its impact.

The intent of each ACH is to improve the health of the entire community by linking community prevention activities and healthcare, with particular attention to achieving greater health equity among its residents. For social determinants of health to be incorporated, linking them to EHRs is necessary. Once connected to the EHR, SDoH data can become part of the clinical workflows as well as various community initiatives. 

Finding a platform to do it all 

From screening to creating seamless workflows and deriving actionable insights through the vast pools of data, there can be multiple challenges for ACHs when addressing the impact of social determinants. Providers, care teams and other stakeholders also require a seamless and secure sharing of data. All of these needs, however, can be satisfied with technology that brings complex analytics and data sharing to an easy-to-use data activation platform. 

Innovaccer’s FHIR-enabled Data Activation Platform provides a platform that simplifies problems related to data and analytics. It helps you create and manage workflows. Through an FHIR-enabled Data Activation Platform ACHs can also:

  • Coordinate care and leverage outreach 
  • Share helpful resources to address patient needs 
  • Collect key insights related to population health
  • Gain insights about the social determinants relevant to a community or individual
  • Achieve interoperability to share healthcare data through APIs





The FHIR-enabled Data Activation Platform also helps members utilize on-demand mobile-based educational materials and provides access to medical records through an easy-to-use and intuitive app.


To learn more about the SDoH management tool click here.

Book a demo for Innovaccer’s
FHIR-enabled Data Activation Platform to find out how it can help improve care delivery.
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