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, or educational or employment opportunities, influence as much as 50 percent of the factors that contribute to health outcomes. Unaddressed, SDoH and the resulting social needs people experience due to these SDoH factors 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.

There is increasing momentum in the health care ecosystem to address SDoH and unmet social needs through closer coordination of health and social care services. In order to effectively address SDoH, health systems must be able to implement three critical components: adequate and sustainable funding; closed-loop referrals between health and social services; and accurate, robust data. Efforts to improve financing and referrals include value-based payment models that enable whole person care, and strong social needs intermediaries such as community health workers (CHWs), promotores, or peer support specialists who can serve as navigators between health and social services.

The robust exchange of health and social data, the focus of this paper, is the other critical component to address SDoH. Effectively leveraging SDoH and social needs data is essential to supporting value-based payment models and care-team coordination across health and social services. When unlocked, shared, and used effectively, SDoH and social needs data become powerful tools with the potential to aid efforts to improve individual health outcomes, implement population health initiatives, and reduce health inequities through upstream interventions that improve the condition of the communities in which individuals live.

However, significant barriers inhibit the collection, use, and sharing of SDoH and social needs data. As health care entities begin to partner more closely with community-based organizations (CBOs) providing social care services, tackling these data challenges will be key to growing and sustaining a system of care that can meet communities’ social needs and address SDoH.

Health plans are in a unique position to assist in addressing the challenges to leveraging SDoH and social needs data. This paper explores challenges to the collection, use, and sharing of SDoH and social needs data, and highlights opportunities for health plans to help overcome these barriers in partnership with other stakeholders. The findings are compiled from interviews with over 40 stakeholders including subject matter experts, health plans, government, health information organizations, CBOs, providers, health analytics platforms, and referral platforms.