Integrating psychosocial risk factors into ongoing care: How to identify patient needs and tailor care planning to optimize outcomes

Provider organizations, payers, and policymakers recognize that health care delivery is incomplete without addressing patients’ psychosocial needs, such as mental health, housing, and transportation challenges. Left unaddressed, psychosocial needs can drive avoidable ED utilization, readmissions, and excess health care spending.

Even providers who understand the impact of psychosocial risk factors struggle to incorporate solutions into ongoing patient management. They lack access to the type of information they need to drive patient interventions. Consequently, care plans often focus on clinical next steps without addressing the underlying risk factors that can drive non-adherence. To optimize outcomes and succeed under value-based reimbursement models, providers need to identify patients’ psychosocial risks and tailor care plan interventions accordingly. Leading population health managers integrate evidence-based assessments into primary care workflows to surface underlying psychosocial risk factors and deploy non-physician staff to direct interventions.

This research report makes the case for incorporating psychosocial needs into ongoing care management, offers a blueprint for staff deployment across different interventions, and provides 18 case studies of providers that have successfully tailored interventions based on psychosocial needs.