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The communities in which we live have a tremendous impact on our health. Social determinants of health (SDoH), holistic health factors such as availability of affordable housing and healthy foods, and educational or employment opportunities, contribute as much as 50 percent to health outcomes. Unaddressed, SDoH and the resulting social needs people experience adversely impact health equity through worse health outcomes, widened disparities, and increased health care costs for vulnerable communities. In communities where these basic needs are met, people experience better health outcomes.

The robust exchange of health and social data, along with a strong community-based workforce and sustainable financing, is a critical component to addressing social needs and SDoH. When shared and used effectively, SDoH and social needs data become powerful tools with the potential to aid efforts to improve individual health outcomes, advance population health initiatives, and reduce health inequities through upstream interventions that improve the conditions of communities in which individuals live.

Why Health Plans

Health plans are in a unique position to assist in addressing the challenges to leveraging SDoH and social needs data. Both through direct engagement with their members and through contracts with their provider networks, health plans hold substantial influence over what kinds of data are collected, and they have the ability to share aggregated data on populations that can help health care providers and community-based organizations (CBOs) make informed decisions to drive improved outcomes.

At the same time, health plans are facing increased regulatory requirements to coordinate health and social care, and to collect and report on SDoH and social needs data. As these state and federal mandates increase, health plans must develop or improve their own capabilities and may need to help their provider networks develop their infrastructure and achieve compliance.

What Health Plans Can Do

Health plans can leverage their resources in a number of ways to support the effective collection, sharing, and use of SDoH and social needs data, including:

Supporting providers and CBOs to address SDoH and social needs

  • Provide funding, technical assistance, and education to CBOs and providers to strengthen their ability to meet social needs data collection and sharing requirements.
  • Leverage administrative resources to collaborate with providers and CBOs to draw down available federal and state funds to support capacity and infrastructure building that will improve their ability to collect and share data.
  • Provide support for pilot projects, including funding, access to software, and technical assistance.
  • Support providers’ documentation of social needs data through value-based payment models, education, and financial incentives for the documentation of social needs through ICD-10 Z codes.

Using data to drive improved care

  • Share aggregated social needs data as well as community-level SDoH data that providers and CBO partners can use to better understand and meet the needs of their patients and community.
  • Reevaluate the timeframe and data used to measure success of community-level SDoH and individual-level social needs interventions.
  • Proceed with a community-first mindset that centers meeting individual and community needs as the end goal.

Improving interoperability and technology infrastructure

  • Encourage electronic health record (EHR) vendors to integrate modules on social needs into their systems in both health care and community settings and reduce the cost for adding on the module to an already existing system.
  • Encourage standards-based data exchange that focuses on domains to advance interoperability instead of imposing requirements on assessment tools or infrastructure.
  • Collaborate with CBOs to ensure they are adopting interoperable data systems capable of sending and receiving information from other platforms.

Ensuring authentic community engagement

  • Engage with individuals and CBOs from the outset of community engagement and program development to build trust and help ensure a program collects relevant data and effectively meets the community’s needs.
  • Maintain a partner role rather than leading with a top-down approach. Supporting CBOs and staff, such as community health workers, promotores, or peer support specialists who have deeply established connections in their communities and act as intermediaries between health and social services, can enhance social needs data collection and closed-loop referrals.
  • Clearly articulate how sharing social needs information can benefit a health plan’s members.

Partnering to scale investment and impact

  • Jointly fund SDoH systems and infrastructure among health plans, including community information exchanges, social service resource locators, and social need referral platforms.
  • Collaborate with other health plans to conduct a joint needs assessment with key stakeholders in a community. Align with local health departments, hospitals, and health centers that are required to conduct community health needs assessments to reduce the burden on participating organizations.


Data are the most important tool that health plans have to improve the health of individuals and communities. The collection, use, and sharing of health and social data is essential for addressing social needs and SDoH. Health plans have a critical role to play in improving our collective ability to effectively leverage social needs and SDoH data to meet individual needs and strengthen communities.

Health plans and the communities they serve need to move beyond piecemeal approaches to resourcing SDoH initiatives. To effectively address SDoH in a community, health plans must work collaboratively towards the shared goal of a healthier member population, whose health and social needs are being met. Collaborative investments in upstream infrastructure are necessary to adequately resource SDoH interventions and can improve provider and CBO ability to collect and share data. Strengthening community efforts through intentional alignment between institutions like health plans will help build a system capable of meeting individual social needs and developing thriving and equitable communities.

Learn more on how health plans can advance the use of data to address social needs and social determinants of health.