Conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes are social determinants of health (SDoH). Understanding the likelihood of negative SDoH factors may impact the approach to which individuals, providers, and health plans approach care, which is why VRI has invested in a deeper understanding of these factors with our members and partners. With a mission to provide remote patient monitoring to save lives and preserve independence for people in need and the caregivers who support them, VRI is leveraging our SDoH data analysis to drive further towards our goal.

In our ongoing studies across several months and thousands of members, VRI examined the prevalence of unmet social needs within a representative Medicare PERS population. In speaking with nearly 3,500 unique individuals, we found that 21% had an unmet social need, but determining the likelihood of an existing need or the type of need was correlated to several factors.

Chronic Conditions
As decades of research have found, there is a significant correlation between SDoH factors and chronic conditions. In our own study, VRI found that that clients who have greater than 1 chronic disease are 30% more likely to also have an unmet SDOH need. Clients with greater than 2 chronic diseases are 33% more likely to have an unmet SDOH need.

Age
In our study, age was correlated to several SDoH needs, but it was often the younger group who needed resources. Clients with unmet food needs were, on average, 6 years younger than clients who were secure in their access to food. Clients who lack transportation were, on average, 2 years younger than those who have consistent access to transportation. Conversely, clients who have trouble accessing medical care were, on average, 3 years older than clients who are secure in their access to medical care.

Risk Score
Finally, VRI used our study to examine and refine our propriety risk score. This scoring system is based on our experience with engagement over time, and it is used as a concise indicator of potential need for health plans and case management team partners. In our research, VRI found that the VRI risk score correlates not only with the number of unmet social needs a client identifies but that a higher risk score correlates with an increase likelihood of unmet needs. A client with a VRI Risk Score greater than 1 is 36% more likely to have an unmet SDoH need than clients with the minimum risk score. Clients with a VRI Risk Score greater than 2 are 215% more likely to identify as having an unmet SDOH need.