Social Determinants of Health (SDOH) Support

Empowering healthcare organizations with integrated virtual care solutions that improve care coordination, reduce total cost of care, and drive success in value-based care.

Who We Serve

Addressing Barriers to Health and Equity

Social determinants—such as access to food, housing, transportation and social support—have a profound impact on health outcomes. CMS is implementing a Health‑Related Social Needs (HRSN) screening tool to identify beneficiaries’ needs and reimburse providers for these assessments. Care management programs like CCM, BHI and TCM are well positioned to engage patients, screen for SDOH and coordinate.

Key Features

HRSN Screening & Documentation

Use standardized tools (e.g., G0136) to assess social needs and document Z‑codes for appropriate reimbursement.

Risk Stratification

Incorporate SDOH data into AI models to prioritize interventions.

Resource Coordination

Connect patients to community programs (food banks, transportation, financial assistance, housing) and track referral completion.

Multidisciplinary Team

Pharmacists, social workers and care coordinators collaborate to address social barriers and medication access issues.

Patient Empowerment

Provide education and coaching to help patients overcome social challenges and adhere to treatment plans.

Benefits & Impact

Improved Health Equity

Addressing social needs reduces disparities and improves outcomes for underserved populations

Quality Performance:

SDOH interventions contribute to higher quality scores in value‑based programs (Star Ratings, CAHPS, HEI)

Reimbursement Opportunities

Billing for HRSN assessments provides additional revenue

Lower Total Cost of Care

Removing barriers enables better adherence and reduces preventable hospitalizations and ED visits

Why PharmD Live®

Our SDOH support program integrates social needs screening into routine care management workflows. Using AI‑driven risk models, we identify social barriers that impact medication adherence and disease control. Our care coordinators and social workers then connect patients with appropriate resources and monitor outcomes.

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