Social Risk and Healthcare: An Introduction to Strategic Approaches

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In recent years, the healthcare industry has started to shift its approach, recognizing that achieving the 2030 Healthy People equity and access goals will require a collaborative, concerted effort. Providers and payers alike are developing their own approaches to address social risk factors, but the path forward is complex. For providers, keeping up with the evolving requirements of what qualifies for reimbursement may feel like a full-time task on top of patient care. Meanwhile, managed care organizations (MCOs) and insurance providers face the high stakes of maintaining or improving their star ratings—critical for revenue and reputation. Forming effective partnerships that address social risks is time-intensive, and the most impactful strategies demand active community engagement to ensure they meet local needs.

Social Risk Strategies in Action

To tackle these social risks, many organizations are expanding their healthcare and life science divisions to contribute to the larger strategy. These groups are working to develop holistic programs that address social determinants of health, leveraging technology to drive innovative, integrated approaches.

The movement toward Whole Person Health has sparked a shift in how healthcare organizations and stakeholders approach patient care to address social determinants of health, embracing the need for more collaborative thinking and knowledge sharing. Industry leaders are stepping up to support these goals by creating knowledge repositories, such as the Kaiser Family Foundation (KFF), who have compiled extensive data and analyses on healthcare issues, providing insights that support better-informed, socially aware decisions.

Additionally, several organizations are dedicated to fostering knowledge sharing. Systems for Action and the Center for Health Care Strategies have emerged as vital facilitators, creating opportunities for healthcare professionals, policymakers, and researchers to come together and share findings and best practices. These collaborative platforms encourage discussions on tackling social risks in healthcare and developing programs that bridge gaps in care. Another group, the Urban Institute, conducts research and shares data to illuminate the social and economic factors that impact health. These knowledge sharing initiatives help decision-makers understand how these elements intersect with healthcare delivery.

Further advancing these efforts, national foundations and healthcare-related organizations have funded collaborative pilots to explore solutions addressing social determinants. The Partnership to Align Social Care (Freedman Health) seeks to create cohesive partnerships among healthcare providers, social care organizations, and communities, providing a framework to ensure patients’ social needs are met effectively and sustainably. For example, they lead a community-care hub workgroup, joining health networks, payers, and nonprofits to align health and social care.

Additionally, the Robert Wood Johnson Foundation (RWJF) has long supported initiatives that aim to create healthier, more equitable communities by addressing the root causes of health disparities. In addition to their many funded initiatives, they run the State Health & Value strategies program which provides information on initiatives and policies at the state level, allowing organizations to access localized data and customize their social risk strategies accordingly. This state-focused approach enables a more tailored response to social risks, recognizing that the needs and resources of each community are unique.

Insights and Challenges

While these exciting initiatives are thriving, the reality of the healthcare landscape is that both community needs and federal policy are constantly changing. Providers play a key role in meeting needs and policy requirements, but due to the rapidly evolving nature of the field, often struggle to have the bandwidth to embrace and conduct this type of work. This introduces a need for additional players to help providers strategically implement social risk strategies, connecting industry, government, and community.

Challenges often vary greatly depending on the community and state in question. The needs of urban areas differ from those of rural communities, where access to healthcare facilities, socioeconomic factors, and other social determinants of health present unique obstacles in both contexts. While federal guidelines provide overarching direction, each state must adapt its strategy to local conditions, meaning they may have different priority areas of focus, such as food security or transportation. Each healthcare provider must also consider the demographics of their served population and that community’s specific social determinants of health. 

While the abundance of data has enabled effective, data-informed decision-making, it’s also introduced complexity. Healthcare leaders face the challenge of leveraging data at different levels—population, community, and individual—to craft targeted interventions, and potential inconsistency in data collection and availability complicates this process. In addition, data-sharing between partners poses significant hurdles, like accessibility and confidentiality.

Community-informed design is another critical component that has proven challenging to implement effectively. While healthcare strategies increasingly recognize the importance of involving local voices, the capacity of community-based organizations (CBOs) to participate meaningfully is limited, as they struggle with resource availability—technological, financial, and human. Addressing social risk requires not only funding and tools, but also a skilled workforce capable of engaging with and responding to community needs. The need for comprehensive capacity-building within these organizations is a persistent challenge that must be addressed to create a resilient support network and sustainably encourage community-informed design.

Finally, the transition from simply measuring outputs to evaluating meaningful outcomes demands long-term commitment and sustained effort. Many pilot programs and early initiatives succeed in showing measurable outputs—such as the number of individuals served, or resources distributed—but translating these into demonstrable improvements in health outcomes takes much longer, which may sometimes be discouraging. This length emphasizes the necessity for a sustained investment in partnerships, technology, and human resources to see initiatives through from conception to impactful, community-level change.

To make real strides, healthcare organizations need partners who can help them manage these challenges and drive lasting impact. By focusing on strategic partnerships and leveraging proven methods for knowledge sharing, data analysis, and capacity building, organizations can move beyond short-term outputs to achieve meaningful, community-level outcomes. Now is the time to commit to comprehensive strategies that address social risks and create a more equitable, effective healthcare system.