How Virtual Care Can Address Social Determinants of Health by Expanding Access and Personalization

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Solving for population health challenges at a macro level starts on a smaller scale in our communities, schools, and environment. If we expand our understanding of health — and measure it — Onduo can contextualize and personalize the care we deliver.

Solving for population health challenges at a macro level starts on a smaller scale in our communities, schools, and environment. If we expand our understanding of health — and measure it — Onduo can contextualize and personalize the care we deliver. Through data-driven identification of barriers to health, Onduo can help identify the most impactful interventions and assist in increasing support and access, to lift up communities in need. While technology alone is not the answer, leveraging best in class, member-centered technology and caring clinicians when needed, has the ability to help us improve individual outcomes at scale.

At Onduo, we’re uniquely positioned to create alignment in the health ecosystem and drive towards value-based care. As we partner with employers and health plans, we are eager to revolutionize care delivery by doing what’s right — supporting for better outcomes and better health.

Social determinants of health (SDoH) are defined by the CDC as, “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”1
Zip code and health
Centers for Disease Control2

Why health plans and employers should care about the impact of SDoH on their members and employees:

1. Supporting good health is good business

Understanding potential social determinants challenges helps better understand and treat the whole person. In order to help keep members and employees healthy and engaged, it’s important to understand what challenges they may face in their day to day lives. This information can direct health plans and employers to invest in solutions that address social needs, such as transportation barriers, stress-reduction programs, and support for child care. Investing in these solutions has the potential to improve member and patient health and well-being.

transportation issues
“Employers provide healthcare benefits and wellness and disease management programs to improve employees' health and well-being--which are largely impacted by SDoH. To get ahead of the cost curve and accelerate value-based care programs, payers are investing heavily in the whole person and removing SDoH-related barriers,” says Adam C. Powell, PhD, president of the Payer+Provider Syndicate.3

2. You can’t change what you don’t measure. SDoH data can help us understand health inequities and identify gaps in care.

We’ve seen that the burden of diabetes and its complications is disproportionately larger for racial and ethnic minority groups, low-income individuals, and rural residents. One way to understand how to personalize care for your population is to measure this. Studies have looked at 2 complimentary area-based metrics including area deprivation index (ADI) score and rurality and optimal diabetes care. The ADI is a composite measure of 17 census variables designed to describe socioeconomic disadvantage based on income, education, household characteristics, and housing.5

health costs
Kaiser Family Foundation6
“Patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. The results call for geographically targeted population health management efforts by health systems, public health agencies, and payers."7

3. Measuring SDoH helps you personalize care

We know that no more than about 10% of a person’s health status is based on the direct care they receive. We have to look beyond the clinical attributes related to this person and factor in things like housing status, local employment rates, food insecurity or transportation challenges for this individual. The collection of the social determinants of health help us craft solutions that fit the individual and allow us to take a more proactive approach to care.”
- Vindell Washington, MD CEO, Onduo
environmental hazards
Health.gov8

We can personalize care by:

  • Bridging access to physicians
    • Providing access to specialists, as clinically indicated, that may not be otherwise available to individuals

    • Leveraging in-app telehealth to remove barriers such as travel, childcare, and the need for time away from work

  • Tailoring program content & coaching
    • Offering culturally-informed and/or ones that consider budget restrictions

    • Delivering empathy-based coaching to evaluate an individual’s condition, behavior, stressors, and barriers

  • Matching member need to available resources
    • Exploring medication adherence issues often surfaces financial constraints that may be addressed through therapeutic alternatives like generics, manufacturer support, and/or manufacturer’s discount card programs

Onduo and Verily on SDoH and Health Equity

Verily wanted to understand the extent to which some SDoH challenges impacted enrollment and outcomes in the Onduo program. Onduo and Verily conducted an analysis of our engaged members to look at factors that impact enrollment rates and factors that may/may not impact equitable outcomes - specifically socioeconomic status, food insecurity. availability, etc.

  • Onduo has and currently does serve members in under-served areas with social determinant needs. In fact, 30% of our members live in low socioeconomic status and 26% live in an area designated as a food desert (based on zip9 or census block mapped from a member’s address)9

  • Individuals with social determinant challenges are more likely to enroll in our program than not

Onduo delivers outcomes that are statistically similar across populations with/without social determinant challenges.10

Population health requires that we explore healthy on a community level — you can’t separate the individual from their community. We should look to develop actionable programs that address the relationship between health status and biology, individual behavior, health services, social factors, and policies.

Together, we can make the future of health more equitable. Download our whitepaper on social determinants of health to learn more.


  1. Social Determinants of Health. cdc.gov. Updated August 2, 2021. Accessed February 11, 2022. https://health.gov/healthypeople/objectives-and-data/social-determinants-health.

  2. National Center for Health Statistics. cdc.gov. June 9, 2020. Accessed April 12, 2022. https://www.cdc.gov/nchs/nvss/usaleep/usaleep.html

  3. Social Determinants of Health and Equity. Onduo by Verily. 2021.

  4. Kurani SS et al. Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. JAMA Netw Open. 2021 Dec 1;4(12):e2138438. doi: 10.1001/jamanetworkopen.2021.38438. PMID: 34964856; PMCID: PMC8717098.

  5. Kurani SS et al. Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. JAMA Netw Open. 2021 Dec 1;4(12):e2138438. doi: 10.1001/jamanetworkopen.2021.38438. PMID: 34964856; PMCID: PMC8717098.

  6. Kearney et al. Americans’ Challenges with Health Care Costs. Kaiser Family Foundation. Dec 14, 2021. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/

  7. Kurani SS et al. Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. JAMA Netw Open. 2021 Dec 1;4(12):e2138438. doi: 10.1001/jamanetworkopen.2021.38438. PMID: 34964856; PMCID: PMC8717098.

  8. Healthy People 2030. health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/neighborhood-and-built-environment

  9. Data on file. August 2021.

  10. Data on file. August 2021.