Prioritizing High-Risk Patients Through SDoH Risk Stratification

Client

Healthcare organizations increasingly recognize that clinical care alone is not enough to improve outcomes — Social Determinants of Health (SDoH) play a pivotal role in patient well-being. This case study highlights how a care management platform applied SDoH-driven risk stratification to identify and prioritize high-risk patients, enabling more timely and targeted interventions. The workflow, embedded within the platform’s Collaborative Exchange module, integrates patient demographics, EHR data, and SDoH indicators to support informed care planning.

The Challenge: Managing Complexity Beyond Clinical Data

Care teams often face challenges when:

Patient risk profiles are incomplete due to missing non-clinical data.
High-risk individuals are not systematically prioritized in outreach.
Coordination between intake, assignment, and care plan creation is manual and fragmented.

These gaps can delay interventions for patients most in need — especially in Medicaid and underserved populations.

The TechVariable Approach

The platform demonstrated a five-step workflow for managing patient intake and care planning:

Verify Demographics
Confirm accuracy of personal information such as name, date of birth, contact details, and address.
Example: Demographics verified for patient “Edgar Jones.”
Risk Stratification
Determine patient risk level using both EHR and SDoH factors (e.g., socio-economic indicators, geographic context).
Example: Patient flagged as High Risk.
Assignment
Allocate the patient to an appropriate care coordinator or manager.
Example: Assigned to a specific staff member with direct contact details.
Intake
Gather baseline information, assess readiness for care engagement, and document needs.
Example: Intake pending completion.
Add or Create Care Plan
Build or update a personalized care plan based on identified risks and needs.
Example: Care plan creation pending.

Impact Delivered

By embedding SDoH risk stratification directly into the workflow:

High-risk patients can be prioritized for immediate outreach.
Care coordination is streamlined from intake to plan creation.
Data accuracy is ensured through upfront demographic verification.
Assignment transparency improves accountability within care teams.

Tech Stack

Potential evolution of this SDoH-driven model could include:

Integration with HIEs to enrich profiles with longitudinal health data.
Partnerships with SDoH resource networks (e.g., Unite Us, Aunt Bertha) to auto-generate community referrals.
Mobile and multilingual outreach tools to engage hard-to-reach patients.
Analytics dashboards for monitoring SDoH impact on care outcomes.

About TechVariable

TechVariable is a healthcare-first technology services firm trusted by payers, providers, and health-tech innovators for its expertise in interoperability, AI-driven analytics, and compliance-focused solution design. With accelerators like SyncMesh and deep domain expertise, TechVariable delivers fast, secure, and intelligent solutions to solve healthcare’s most pressing operational and clinical challenges.