Social Determinants of Health and Predicting Care Outcomes

According to health.gov, “Social determinants of health (SDOH) are 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.” Understanding SDOH is important for anticipating health complications and ensuring positive health outcomes and improved quality of life. 

As homecare providers, your role is to ensure client satisfaction and provide the best care possible, which has many factors, including the use of technology. Generations Homecare System is designed to equip providers of care with the tools they need to monitor changes in the environment where their clients reside. Real-time alerts to agency professionals signify potential threats to the wellbeing and safety of individuals who require homecare services. 

Below we have identified three SDOH and how they may affect the health of the individuals you serve. These are just three ways in which social determinants play a role in an individual’s overall health and quality of life.

Don’t miss the video overview at the end of this blog post!

Isolation and Loneliness:

Isolation and loneliness play a prominent role in the overall health of an individual. According to Humana, more than a quarter of the United States population now lives alone. With living alone comes the risk of loneliness, leading to feelings of isolation. In addition to the aging of the baby boomer population, this number is increasing significantly. Thus, isolation and loneliness play a key role in health risks as well. 

Luckily, there are many ways a homecare provider can help those feeling isolated or lonely. Here are some ways to help:

1. Encourage them to do activities they love

Though it may sound simple, encouraging those lonely to do activities they love goes a long way. Often those who are lonely lose motivation for the activities they love doing, and picking them back up may help their loneliness.

2. Spend time with them

Spend quality time with those you know may need it. Due to remarkable technological advancements, it has been made easy to connect in more ways than one. A phone or video call from a loved one or a homecare professional is sure to brighten their day.

3. The Friendship Line

The Friendship Line (800-971-0016) was developed by The Institute of Aging (IOA) for those 60 and older. When called, they are connected to a trained professional who offers a listening ear. 

Housing Status:

Housing status is another important factor in the quality of life of an individual. According to HealthAffairs, four pathways connect housing to health care. These four pathways are; stability, quality and safety, affordability, and neighborhood. Stability allows for peace of mind. The fear of homelessness or being homeless, on the other hand, can strike a massive toll on the mental and physical health of a person. Quality and safety allow the assurance of feeling safe in one’s own home. However, often in an environment that is not taken care of well, issues can arise that may affect the resident. This is where homecare providers often play a critical role in identifying environmental risks and mitigating them whenever possible.

Numerous programs have been developed to help with housing issues. Here are some of the organizations:

1. Housing Choice Voucher Program

This government program helps low-income adults find housing. If eligible, housing vouchers are given to those in need, and the individual(s) can choose a home to redeem their voucher.

2. Supportive Housing for the Elderly Program

This program is focused on funding the development of housing for the elderly. Organizations can apply for funding to acquire, construct, or rehabilitate low-income housing.

3. Eldercare Locator 

This service has a mission of connecting the elderly with resources including home and community-based providers. This site offers help in many areas, and housing is one of them.

Food Insecurity:

Food insecurity is common amongst older adults, especially those with chronic health conditions. A 2018 study shared by the CDC showed a linkage between food insecurity and chronic illnesses. The most common diseases were diabetes, hypertension, and arthritis. High healthcare costs for these illnesses make it difficult for many to put food on the table.

To help seniors battling food insecurity, the government offers the Supplemental Nutrition Assistance Program (SNAP). When granted access to SNAP, people are eligible to purchase healthy food with government funds. In addition, SNAP allows those eligible to maintain the independence of grocery shopping and choosing their food while providing the ease of funds. 

Meals on Wheels America is another organization with a great goal, to provide seniors with the support they need to be independent. Meals on Wheels providers meals to seniors while also providing company. As seen on the website, nine out of ten seniors using the program have reported that Meals on Wheels helps them live independently.

It can be said that bringing awareness to the issues of Social Determinants of Health is essential. This is because it has allowed us to educate ourselves and learn more about them. It also has allowed the government and other organizations to develop programs and provide resources to those in need.

Monitoring Social Determinants of Health

Understanding the living conditions and risk factors of the individuals helps ensure positive health outcomes and overall higher quality of life. The Wellness tool in Generations Homecare System gives homecare providers the power to monitor risk factors in real-time. Caregivers in the client’s home complete Wellness questions during their visits via the mobile app, and the homecare management team is notified of results that they deem high-risk. Below are a few examples of questions to add to your agency’s Wellness component in Generations:


  • Does this person have a nearby friend or family member to contact in the event of an emergency?
  • Does this person report to have satisfying personal relationships with friends or family members?

Housing status:

  • Does this individual have working electricity and/or gas?
  • Does this individual have clean water available?
  • Does this individual have a working telephone?

Food security:

  • Does this individual have a meal delivery service, such as Meals on Wheels?
  • Does this individual have fresh fruit or vegetables in the house?
  • How many days since this person has had a visit from Meals on Wheels?

It is important to identify signs of Social Determinants of Health early on, and frequently thereafter, to mitigate certain risk factors vulnerable citizens may face as they age. The Wellness tool in Generations allows caregivers, and their managers, to track signs of Social Determinants of Health and other risk factors in real-time.

Learn how to track changes in SDOH and more about Generations Homecare System by downloading this overview booklet.

download button