When it comes to health outcomes, what happens outside the doctor’s office often matters as much—if not more—than what happens inside.
Can you get to your appointment? Do you have enough food at home? A safe place to sleep? These seemingly personal struggles have a direct and significant impact on health outcomes.
80% of health outcomes are tied to non-medical factors like housing, transportation, food security, and social support. Addressing these health-related social needs (HRNs) is crucial for improving health outcomes and reducing healthcare costs.
For years, community-based organizations (CBOs) have stepped in to fill these gaps, providing essential services to those who need them most. But as value-based care (VBC) models evolve, it’s becoming clear that CBOs alone aren’t enough. Healthcare organizations must build sustainable social care strategies that prioritize the right patients, improve social care coordination, and optimize resources.
Why Having a Social Care Strategy Matters
An effective social care strategy goes beyond simply providing resources—it requires a structured, long-term framework. Without this, social care efforts can become fragmented, inefficient, and difficult to scale.
To make a real impact, healthcare organizations need a social care strategy that brings together COB services, paid social care solutions, and technology. With the right mix, patients can get the support they need when they need it, while care teams can work more efficiently, improve outcomes, and make better use of resources.
So, where do you begin?
1. You Can't Do Everything for Everyone—Target the Right Patients
It’s tempting to cast a wide net when offering social care services, but spreading resources too thin doesn’t actually move the needle. The key?
Targeting the right patients.
Take transportation as an example:
- No transportation = Missed doctor's appointments
- Missed appointments = Worsening conditions
- Worsening conditions = Emergency room (ER) visits
However, not everyone needs transportation assistance. So, how do you figure out who does?
Use data.
Instead of guessing, leverage data-driven insights to identify high-risk patients—those missing appointments, frequently visiting the ER, or managing chronic conditions without proper support.
With predictive analytics, organizations can anticipate and prioritize at risk patients before problems escalate, allowing for earlier intervention and reduced healthcare costs.
Data-driven insights aren’t just about identifying patients—they’re about making sure people get the support that actually fits their needs. One person facing food insecurity might need a pantry box delivered to their home, while another might be better served by a local food bank. By using data to match people with the right resources, healthcare organizations can provide more meaningful support.
2. Know What's Reimbursable (and When to Leverage Community-Based Services)
Social care is essential, but budgets aren’t unlimited. A sustainable strategy requires understanding which services are reimbursable, which need discretionary funding, and when to refer patients to community-based services that can provide support at no cost.
What’s Reimbursable?
- Mental health services – Reimbursable by CMS if patients meet clinical criteria
- In-home modifications – Medicaid-funded for dual-eligible patients with a fall-risk screening
What’s Not (But Still Valuable)?
- Food and nutrition support (e.g., pantry boxes, medically tailored meals)
- Transportation assistance
- Advanced care planning
While these non-reimbursable services still provide critical benefits, they require discretionary funding. When patients don’t meet eligibility requirements but still require services, community organizations—such as food banks and nonprofits—can help fill the gap at no cost. Referring patients to these services can extend healthcare impact without stretching budgets. Before making a referral—whether to a CBO or a paid service—it’s important to check availability, eligibility, and whether the service is the right fit for the patient’s needs.
Investing in social care can lead to significant cost savings. Research shows that every $1 spent on social service referrals can generate a $4 return on investment.
The key is ensuring patients receive the right care at the right time through the most cost-efficient channels.
3. Care Teams Need the Right Tools (Because They're Overloaded)
A great social care strategy is worthless if care teams don’t have the capacity to execute it. Right now, many care teams are overloaded with manual processes, patient coordination, and paperwork.
The solution? Smart technology.
Innovative social care platforms can:
- Automatically identify high-risk patients using real-time data
- Match patients with the right services instantly
- Streamline referral tracking, cutting administrative work and delays
For example, one ACO using Spatially Health’s platform reduced manual clicks from 32 to just 3, saving care managers hours of work every day.
But technology isn’t just about efficiency—it’s about better patient engagement. With augmented navigation, digital referrals, and a closed-loop referral system, care teams can provide ongoing support without additional workload.
4. Track What's Working—And What's Not
A social care strategy isn’t something you can set up and forget. Success depends on continuous tracking and refinement based on patient outcomes and overall costs.
What Should You Measure?
- Are patients using the services they're referred to?
- Are these programs reducing avoidable ER visits and hospitalizations?
- Are these interventions driving cost savings?
A closed-loop referral system gives care teams the tools to follow patient journeys, track engagement, and adjust care plans as needed. For leadership, it offers valuable insight into trends and key performance metrics to improve care delivery for socially vulnerable populations.
Final Thoughts
A sustainable social care strategy isn’t about doing more—it’s about doing it more effectively.
Here’s the playbook for success:
- Target and Prioritize Patients – Focus on high-risk patients like those with chronic health conditions and multiple health barriers, ect.
- Optimize resources – Match and connect patients to the appropriate services—internal programs, CBO, or paid social care services.
- Empower care teams – Use technology to lighten administrative burdens and streamline social care referrals.
- Measure and refine – Track referrals and outcomes via a closed-loop referral system to assess impact, and adjust as needed.
By replacing a lot of the guesswork with data-informed social care, healthcare organizations can make more informed decisions, ensuring resources are used effectively to enhance patient outcomes, support care teams, and lower costs of care.
Ready to take the next step? Spatially Health’s platform helps organizations identify high-risk patients, automate referrals, and track engagement—so you can build a sustainable, high-impact social care strategy with confidence.
Let’s make social care more efficient and impactful together.
