Home-based care providers have an unmatched view of barriers that can undermine care outcomes known as social determinants of health.

Even without an immediate financial incentive, some home-based care providers are addressing these social determinants of health to remove obstacles to care — and to give frontline workers a better chance to deliver the services patients need.

“Home healthcare can play a large role in helping maintain social determinants of health for older adults,” Catherine Ettman, assistant professor within the health policy and administration department at Johns Hopkins University, told Home Health Care News. “Home healthcare workers can ensure that the home is a safe place to be, that it is equipped for older adults to move about freely and safely.”

Social determinants of health are non-clinical factors that affect health outcomes and risks. Research suggests that social determinants of health can affect as much as 50% of county-level variations in health outcomes, compared to the 20% seen from clinical care.

Social determinants of health include economic stability, social and community context, education access and quality, healthcare access and quality and neighborhood and built environment, according to the United States Office of Disease Prevention and Health Promotion. Credit scores and religious affiliations can also act as SDoH, Ettman said.

By virtue of working within a patient’s home, home-based care workers are granted greater access to a patient’s SDoH-related challenges than many types of healthcare workers, who often only see patients for about 15 minutes every few months. This level of insight “can’t be replicated elsewhere,” Evan Worrell, senior director of operations for Modivcare’s West Virginia-based operations, told HHCN. Worrell is also the chair of the Health and Human Resources Committee in the West Virginia House of Delegates.

Denver-based Modivcare provides non-emergency medical transportation, in-home personal care and remote patient monitoring across 35 states.

While home-based care workers have unique insight into a person’s SDoH, risk-bearing providers and payers must weigh the ROI of investing to address their patients’ and clients’ living situations.

“Whoever is holding the risk on someone’s cost of care, they are going to want to see evidence that the investments they make pay back,” Chelsey Berstler, executive vice president and president of personal care services at Modivcare, told HHCN. “These are things that are in balance with health outcomes and with laws and regulations, but ultimately, there’s not some magic well of funds that never dry up. We have to be mindful of using dollars wisely and stewarding those dollars wisely.”

When addressing SDoH, not all ROI can be quantified. And yet, providers such as Modivcare take steps to tackle obstacles to a client’s well-being. Worrell describes how Modivcare caregivers will help patients with six-month Medicaid redeterminations to ensure their eligibility still exists, as well as connecting clients with food assistance programs, coordinating transportation services and addressing social isolation.

“There are a lot of different things that you don’t see the ROI in that we can’t quantify in those specific instances, but we know that drives a better health outcome, a better quality of life for that client,” Worrell said.

Research shows that addressing SDoH-related barriers lead to lower hospital readmissions, Berstler said. Nourished patients are less likely to fracture bones and experience other orthopedic incidents, and individuals with anxiety and depression tend to have higher comorbidities than those who don’t.

A 2024 study published in JAMA Network looked at social determinants of health at the cost level for both private insurers and Medicare and Medicaid payments. The researchers analyzed nearly 15,000 insured adults and found that individual-level social determinants of health factors were “significantly associated with US healthcare expenditures.”

For instance, Medicare beneficiaries who were “very confident” in covering unexpected expenses billed an average of $3,744 less in annual Medicare expenditures, suggesting a connection between wealth and Medicare billing.

“The evidence does exist,” Berstler said. “I think that the harder question is, how do we triangulate it so that we can bring all the pieces together, so that those making the next investment can benefit from the value that’s created, or vice versa.”

Addressing SDoH

While research shows an overall return on investment when addressing social determinants of health, home-based care providers must determine when to take action to address their patients’ SDoH.

“As healthcare providers, we recognize some people live on top of the hill, some people look at the bottom of the hill, but we have to be consistent in our care,” Faris Flournoy, CEO of Flournoy Health Systems, told HHCN. “This is where [as] home and community-based providers, we have to partner with community, other community resources to go through and meet those needs of those individuals.”

Milledgeville, Georgia-based Flournoy Health Systems is a home care management company operating in Georgia and Indiana through a portfolio of brands, including Primecare Home Care and Just Care Home Care.

Flournoy describes one instance where a bed bug outbreak affected the areas Flournoy Health Systems served. The company’s policy stated that caregivers could not go into a home with bed bugs since it could spread to other patients.

“We had to think outside the box,” Flournoy said. “We recognized we had something not in the realm of healthcare, but we had to go through as a responsible healthcare provider if we truly cared about those particular clients. If we’re not in the home providing care, they’re going to have a decline.”

The company connected with pest control services to treat the homes of these patients, he added.

The home health agency worked with family members and business owners in the area to remediate the bed bugs and allow their caregivers to go back into the homes. Doing so meant Flournoy Health Systems lost a bit of profit, but it was “the right thing to do” so that the nurses could actually care for the patient, he said.

In the end, addressing these social determinants of health can have compounding impacts across the broader community, Flournoy said.

“It’s like the butterfly effect. It really, truly matters. It just takes providers to do it differently, and recognize that, everyone just can’t say no,” Flournoy said. “It may sacrifice a little profit, but it’s for the greater good of that particular community.”