Identifying risk attributes — social determinants of health (SDOH) — for populations can enhance an organization’s ability to develop sound, data-driven interventions that can influence change, enrich wellness, and improve profitability.

Income and wealth are significant contributors to disparities in health. Living in poverty and/or being financially distressed are often linked to higher risks of being hospitalized and poorer well-being in general. This can also add to the risk of other insecurities, such as housing, food, and transportation. According to an Urban Institute and Virginia Commonwealth University brief, low-income adults are three times more likely to experience limitations in activity due to chronic illness, as well as higher rates of diabetes, stroke, heart disease, and premature death.

Given that up to 80 percent or more of a person’s health outcomes are directly related to where they’re born, live, and work, (National Academy of Medicine) delving into socioeconomic factors correlated to overall wellness can increase your understanding of — and help mend — the health risks associated with individuals and populations.

Identifying risk attributes — social determinants of health (SDOH) — for populations can enhance an organization’s ability to develop sound, data-driven interventions that can influence change, enrich wellness, and improve profitability. More specifically, this data can be used at an individual and community level to:

  • Decrease screening burdens at the point of care
  • Improve predictive analytics and risk stratification efforts in conjunction with clinical and claims data to identify areas of risk and recurrence
  • Glean insights into lesser-known social risk factors to develop more targeted population health strategies
  • Yield more informed referrals to community-based partners

Currently, per data from the Kaiser Family Foundation, over one in 10 citizens of the U.S. population are living 200 percent below the federal poverty level — the equivalent of a family of four having an annual salary of $52,400 or lower (2020 Percentage Poverty Tool). So there’s a lot of opportunity for health care organizations — providers and payers alike — to draw actionable insights from reliable SDOH information. The following organizations have seen measurable success by using this data to develop interventions:

  • In the Health Research & Educational Trust report “Food Insecurity and the Role of Hospitals, ProMedica identified patients in need of food and directed them to a food pantry, resulting in a 3 percent decrease in emergency department usage and 53 percent reduction in readmission rate.
  • Per an evaluation done by the New York State Department of Health, New York State implemented a supportive housing program and saw a 40 percent reduction in inpatient stays and 26 percent reduction in ED visits.
  • Calvert Health, as outlined in a Health Research & Educational Trust report, identified transportation barriers and saw a 9 percent reduction in readmissions after addressing them.

When looking to identify the best housing, transportation, and food interventions, it’s important to examine the right combination of data sources. Information from sources such as consumer data, public records and sources, aggregated credit, and proprietary sources can be particularly useful. This may include contact information (phone number, email address), address history, and transportation details, as well as housing and employment data. 

TransUnion Healthcare is uniquely positioned to deliver individualized (evidence-based data from 90,000+ sources and matched at the patient-level) and aggregated (neighborhood information down to the ZIP +4 level) datasets. Armed with accurate risk data from disparate sources, your organization can see both individuals and communities with more granularity. This comprehensive view helps enable more actionable risk mitigation and segmentation strategies by using socioeconomic data, as well as your own clinical and claims information, to determine a patient’s risk level for utilization. This helps enhance your in-house risk scores— a win-win for you and your members.

For more information on how to build effective healthcare interventions backed by extensive, market-leading data, download our quick guide or visit

About the author

As Senior Vice President & Chief Strategy Officer, Jim Bohnsack is responsible for driving growth through sales, partnerships, new solution development and acquisitions for TransUnion Healthcare. Jim has spent his entire 20-year career focused on various aspects of the healthcare industry. His experience ranges from strategy to process, services to technology and health systems to corporations.

Prior to returning to TransUnion Healthcare, Jim served as the President and Chief Financial Officer for Strivant Health, a private-equity backed physician revenue cycle management company based in Dallas, Texas, and as Senior Vice President of Provider Growth for CIOX Health, a New Mountain Capital portfolio company. Throughout his career in the healthcare industry, Jim has held various leadership positions at Conifer Health Solutions, TransUnion Healthcare, Deloitte and Ernst & Young.

Jim holds a bachelor‘s degree in business administration and a master’s degree in healthcare administration from Trinity University in San Antonio, TX.