• Total Shared Savings Revenue by Organization- $1.5 Million Annual
  • Total Care Management Fee Revenue by Organization - $300K Annual
  • Increased Hypertension Control to 80%
  • Increased Diabetes Control to 65%
  • Decreased ER Utilization 25%
  • Chronic Care Management Enrollment Average 40% of total Medicare Lives
  • Chronic Care Management Revenue by Organization- $50K monthly

Social Determinants
of Health

Social Determinants of Health (SDOH)

Social Determinants of Health (SDOH) are complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and social factors. SDOH are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world. To reduce health disparities, address social risk factors, and achieve health equity, populations need support to address cultural, socioeconomic, racial, and regional health care disparities. Priority SDOH issues include housing, food insecurity, physical safety, and transportation.

As part of Target Health’s population health management process, patients are asked critical SDOH-related questions during a health needs assessment to identify their individual SDOH needs. Once the patient specific needs are identified, the Target Health team ensures active referrals to community-based organizations occur and performs follow-up outreach to confirm the referral loop was closed.  

Target Health collaborates with healthcare organizations and the Primary Care Provider by reporting special SDOH diagnosis codes identified during the needs assessment. The special SDOH ICD-10 Z-codes identified are made available to the provider to include on their claim submission. This allows healthcare organizations the ability to understand treatment, prevalence, and admission patterns related to non-clinical psychosocial and socioeconomic needs of their members. Appropriate use of the ICD-10 Z-Codes helps advocacy efforts for the variety of support services required of patients/members struggling with psychosocial and socioeconomic issues. For example, collating supporting data for “Z59.0 for homelessness” as a co-morbidity provides value in managing that member’s SDOH needs and improving clinical to financial decision-making.