The Social Needs Funnel: Measuring the Impact of Community & Social Service Interventions on Population Health Outcomes


As the US Healthcare System continues to lag behind other developed nations in the relationship between healthcare expenditures and outcomes, more healthcare organizations are responding to research demonstrating that medical care is not the primary factor that determines the health outcomes. Indeed, major healthcare organizations are shifting investment towards initiatives that can help address the behavioral, environmental, and social determinants of health (SDoH).

While insurers and providers alike recognize that the populations they care for have a variety of social needs – and when those social needs are addressed, health outcomes are improved – there continues to be minimal visibility and understanding of which interventions are most effective in impacting key outcomes metrics, including readmission rates.

A Framework for Measurement

Most SDoH initiatives are still in their early days, but it is worthwhile to borrow tactics that have proven effective in other sectors as the industry seeks a foundation for defining success and optimizing these efforts.

Borrowing from funnel frameworks used for decades across several industries, the “Social Needs Funnel” is a framework Healthify has created to help organizations shape how they measure SDoH investments.

The concept is simple: in a given population, there are a variety of social needs, like food insecurity, homelessness, or unemployment, which drive the lion’s share of adverse health outcomes. When these social needs are addressed, the population’s health outcomes are improved. But first, there are a series of key milestones that must occur to address a social need:

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Need Identified: A care professional – typically a care manager, social worker, or medical professional – must work with a vulnerable individual to identify a specific need in their life that is putting them at risk for poor health outcomes. For example, a Medicaid beneficiary’s inability to pay utility bills this month may increase her stress levels, which are known to increase risk levels for a variety of medical conditions.

Resource Found: That same care professional will often work with the member in need to identify agencies in her community which provide services that could help. For example, the care manager might search a community resource directory tool for “utility assistance” resources, to find three community agencies offering this service.

Service Provided: Once a resource has been found, there is a handoff phase, whereby the care professional encourages the member to connect with a community agency and receive the appropriate service. The step between “Resource Found” and “Service Provided” may contain the most significant barriers, as people in need are often challenged with navigating a typically complex, resource-constrained system that includes many different people, organizations, application forms, etc.

Outcome Improved: Finally, it’s important to recognize that the fact that a community agency has provided a service does not necessarily indicate that the underlying social need has been addressed. While certain community and social service interventions have been shown to lead to improved health outcomes, it’s essential for organizations to measure each intervention’s individual impact, as there are assuredly some that work and others that don’t.

In between each of these milestones, there are barriers that cause drop-off points. For example, if a person in need is unable to connect with the utility assistance agency she was referred to, she may not receive any help covering her utility bills, leaving her at high risk for stress-related medical conditions. By measuring the conversion rates between each milestone, organizations might begin to understand the barriers and develop measurable interventions that improve the conversion rate between each milestone, effectively increasing the odds that a given social need is resolved.

Putting it to the Test

If your organization is developing a SDoH initiative, the most important question is likely, “how will we know if we’re successful? What return do we expect on this investment, and how do we know that this is the right place to spend our population health dollars?”

This is where the Social Needs Funnel framework can help. Put in place tracking mechanisms to log when needs have been identified, resources have been found, services have been provided, and outcomes have been improved. Work to associate each intervention with an individual, so that health and financial outcomes data can be attributed back to the various interventions that occurred higher up the funnel. With the right measurement foundation in place, the US healthcare system may just be able to guide more people in need to the most effective interventions, closing the gap between healthcare costs and outcomes.

Talk to a Healthify representative today about how your organization can apply a robust measurement framework towards your SDoH initiatives.

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