How to address social determinants of health (SDOH) with remote patient monitoring

Care teams face more than treating and managing the actual chronic diseases of patients. Socioeconomic and environmental factors also impact access to care, patient engagement, treatment adherence, and clinical outcomes. These social determinants of health (SDOH) in some cases are barriers to equitable and connected care. However, there are ways to address them when SDOH and remote patient monitoring (RPM) are taken into consideration as part of the care plan.

Can RPM make a difference in addressing SDOH? Data and the outcomes of those practices and organizations using the Optimize Health RPM solution point to a resounding yes.

How does SDOH impact the care and outcomes of chronic disease patients? 

According to a study on the relationship between determinant factors and health outcomes, only 10-20% of a person’s health is the result of clinical care. The other 80% relates to SDOH factors—economic stability, education, and food security, for example. 

SDOH has six categories, as defined by the Kaiser Family Foundation:

Each of these can dramatically affect a chronic condition patient’s ability to receive care and adhere to treatment plans. In this ecosystem of determinants, there are many scenarios of how these attributes impact chronic disease management. 

For example, someone’s lack of transportation could keep them from regular visits or getting prescriptions filled. Another is looking at socioeconomic status; those in poverty often have limited access to healthier food options, which can cause the development of chronic conditions such as diabetes. 

SDOH is a cause of chronic diseases and deters improved outcomes.

Chronic conditions are rampant in the U.S., with 6 in 10 having one and 4 in 10 having two or more. The outcomes for these individuals vary, and SDOH is a catalyst for these being more adverse. Research indicates that SDOH contributes to chronic disease disparities in the U.S. among racial, ethnic, and socioeconomic groups. They can even be a factor in the onset of a condition. SDOH strongly links to the onset of chronic diseases and increases the risk of hypertension and diabetes. 

SDOH is a powerful component in chronic disease management. The reason is that managing these conditions requires engagement by the patient and adherence to medication and care plans. With factors like feeling unsafe, low literacy, or struggling to make ends meet impacting a patients’ life, it’s challenging to get them to participate in their own health.

Treating the disease and SDOH

Physicians must then “treat” not only the disease but also the SDOH and its limitations. The healthcare system has adapted in an attempt to do this. The introduction of telehealth and its growth during the pandemic, along with new reimbursement models, has been a key component. A survey on the topic found that 63% of patients “strongly agreed” that telehealth addressed SDOH concerns. Virtual visits are only part of the remote care opportunities to ease the gaps caused by SDOH. Remote patient monitoring is the next step.

Remote patient monitoring and social determinants of health: how RPM addresses these challenges

Addressing SDOH in your patient population starts with identifying the SDOH during patient encounters. Asking questions about access, safety, and other environmental and social factors that could impact managing their chronic conditions fulfills this step. 

Once established, you can use an RPM program to expand care outside traditional settings which eliminates the limitations SDOH puts on patients regarding access to care. Patients would be able to take daily readings and their vital data will be synced and monitored by a care team member remotely. RPM delivers more data and increases touchpoints, which helps bring better health outcomes. 

A successful RPM program requires taking SDOH into account and driving engagement. Making it seamless and simple involves:

When SDOH is in the picture, how you structure and support RPM matters. When launched successfully, research suggests improvements in health. Our work with practices and organizations using RPM supports this. Some data points include:

RPM increases health equity

Also of note in the RPM and SDOH landscape is the topic of health equity. Health equity has a huge gap, impacting those with SDOH living in rural areas the most. For example, rural Americans are more likely to die from heart disease, cancer, and stroke, according to the CDC. There are many reasons for this, with lack of access, insurance, and financial instability influencing this statistic. 

For those treating these patients as an FQHC (federally qualified health center) or RHC (rural health center), you are trying your best to make sure your patients don’t add to this statistic. These organizations have a mission to improve health equity, and RPM provides a great means to do this. The 2024 CMS Physician Fee Schedule (PFS) offers optimistic news for FQHCs and RHCs to expand or launch RPM. Beginning January 1, 2024, they are able to bill using G0511, enabling billing for RPM services multiple times per calendar month.

This change offers an opportunity for FQHCs and RHCs to address SDOH with RPM.

Partner with Optimize Health to expand RPM and its ability to combat SDOH

SDOH is a complex ecosystem, and RPM is one more tool to mitigate the impact of these on a patient’s health. Ensure you have an RPM partner to streamline and facilitate engagement.

Whether you have an RPM solution or want to build one, we can help! Our software platform, clinical monitoring services, and patient engagement, onboarding, and education offerings deliver the foundation you need to drive better clinical outcomes for patients impacted by SDOH. Let us handle the logistics and customize a program for you while you focus on patient care. Get started with a free consultation today!