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More than half of U.S. adults live with at least one chronic disease, yet traditional health care approaches often overlook a key factor: social determinants and drivers of health (SDoH). These factors, including economic stability, housing, transportation and education, account for up to 80% of overall health outcomes, leaving traditional medical care contributing only about 20%.

While we're starting to see more organizations take innovative steps to address these barriers, including implementing the chronic care model (a framework for delivering quality care to patients with chronic disease) more work needs to be done. Addressing these needs is critical not only for combating the rise of chronic conditions and reducing the total cost of care, but also for fostering a healthier, more productive workforce.

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To truly move the needle on chronic disease management, employers and health care organizations must fundamentally rethink their approach to prevention and care delivery. To do so, they must consider implementing both new tools and initiatives that recognize and address the socioeconomic factors influencing employees' chronic health conditions.

Identifying health barriers through data

To effectively address employee needs driven by SDoH, employers must first substantially invest in tools that identify the barriers they are experiencing. Employees in lower-wage positions, for instance, visit emergency departments three times more frequently and face higher risks of chronic illness due to unmet health-related social factors. To address these challenges, employers must provide resources, such as access to robust screenings, standardized documentation, data integration and targeted interventions.

These tools, especially data collection and analytics, are critical for identifying care gaps and understanding the broader socioeconomic and cultural factors influencing employees’ behaviors. For example, an employee managing diabetes while facing food insecurity is less likely to achieve glycemic control without adequate nutritional support. Leveraging data allows care teams to identify at-risk employees and deliver tailored interventions that address both of their clinical and social needs. By understanding these barriers, employers can develop targeted solutions that help employees prevent or better manage their chronic conditions.

Implementing solutions for SDoH to improve employee health

As employers begin to implement new solutions, we can expect initiatives like partnerships with health care organizations and efforts to reduce social and health-related stigma to take shape. We’re already seeing employers partner with health care organizations to enhance employee wellness, and it will continue to play a key role in improving chronic care. With 3 in 4 employees with chronic health conditions needing to manage their conditions during work hours, offering onsite or nearby care for employees helps reduce challenges, such as transportation and time constraints, increasing access to timely medical services. These collaborations demonstrate the meaningful impact of addressing SDoH for employees, as healthier workers lead to reduced absenteeism and better morale.

Beyond partnerships, organizations must also take proactive steps to reduce stigma around social and health-related issues. A Harvard poll finds that nearly 30% of employees don’t want to think they’re less able to work due to their chronic conditions, while 18% said they are worried they’d be passed over for work opportunities. Building trust among employees—particularly those disproportionately affected by social inequities—requires ongoing engagement, cultural humility and sensitivity to diverse needs, such as flexible time off, remote work or financial support.

At the same time, these initiatives generate valuable insights into the broader health of the community. Metrics such as screening rates, health outcomes, return on investment (ROI), and clinician wellbeing are critical for guiding these efforts. Similarly, tracking the impact of SDoH interventions on clinician satisfaction can reinforce the importance of purpose-driven care, helping to prevent employee burnout and improve staff retention. These insights not only shape more effective health care strategies but also highlight the need for a holistic approach that addresses both medical and social aspects of health.

Ultimately, addressing SDoH requires a collaborative, data-driven approach that integrates social care into workplace health strategies. Providing support for employees facing challenges like caregiving or managing chronic conditions leads to better health outcomes, reduced costly health care visits and improved workplace performance. By prioritizing social factors alongside traditional health care benefits, employers can address chronic conditions at their source, fostering a more inclusive workplace while driving long-term business success.

Dr. Alina Urriola, Associate Medical Director, apree health

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