After this year’s JP Morgan Healthcare Conference, even with investments in healthcare IT trending down, I feel the industry is finally moving forward. I say this because social determinants of health are finally gaining the recognition it deserves in the industry.

Addressing social determinants of health is not a new concept in healthcare. Community Health Centers (CHCs) and Federally Qualified Health Centers (FQHCs) have been spearheading this effort for years. Having worked closely with these organizations, we have found that better health is enabled when people are informed and have means to access helpful programs that go beyond healthcare.

According to a 2015 study, “Poverty affects health by limiting access to proper nutrition; shelter; safe neighborhoods in which to learn, live, and work; clean air and water; utilities; and other elements that define an individual’s standard of living.” “Poverty and Health – The Family Medicine Perspective (Position Paper)”, Czapp, MD, Kovach, MSc, CHES, et al., American Academy of Family Physicians (, 2015

Plain and simple: a person’s standard of living affects their health. But how do you reach this underserved population effectively?

The secret: A well-built patient relationship.

Healthcare is hyper-localized. For the patients to effectively communicate a need for additional assistance, they need to have a relationship with a provider that lasts.These meaningful relationships are built when the provider and patient are from the same community. This localization creates a better understanding for the environmental stressors the patient may be facing.This is what makes FQHCS and CHCs successful when it comes to providing this type holistic care to their communities.

Collecting information to address social determinants of health is not as simple as a quick name or date of birth. It requires a high level of engagement and empathy from enrollment counselors for the patient to open up about their very personal situation outside of the basic demographics.

For health centers, this starts at enrollment. More often than not, it is easier to collect this personal information during the enrollment process. Patients are more vulnerable and prepared to provide the necessary information given their urgency to see a provider.

PointCare is helping health centers provide reportable data on social determinants of health through the industry’s first Total Coverage Management platform. The data shows that in addition to qualifying patients for healthcare coverage, 86% of the patients screened by PointCare also qualify for additional assistance, such as food, cash, or premium support. 53% of the patients qualify for programs with food or cash assistance, helping support the basic elements patients need to live a healthier lifestyle. This data allow communities to proactively better address the needs of their population.

As the industry begins to scratch the surface on social determinants of health, I recommend they look to FQHCs and CHCs as a model to provide the care patients need to truly transform population health. Forging these long-lasting relationships and providing additional assistance programs that directly affect a patient’s well-being is taking a much needed systematic approach to managing coverage. This brings a true holistic healthcare into reality, going beyond the clinic walls by impacting the patient’s physical and financial health through proper coverage management. This not only creates a valuable relationship and insight to our population’s health, but also builds trust in the provider (and in the healthcare industry).


Everett Lebherz
CEO and Co-founder, PointCare