Reducing Disparities and Promoting Health Equity in Underserved Communities with Social Determinants of Health

The new year is a time for reflection and goal-making. As the year begins, so do our aspirations on how we can improve. In the world of healthcare, one of the biggest improvements we need is health equity. It doesn’t matter how much we improve our services and our technology if only a select few will be able to access it. The only way to truly deliver good healthcare services is through ensuring everyone gets the same level of care in spite of the barriers that may be in the way. So as 2025 begins, let’s all strive to reduce disparities and promote health equity in underserved communities this year!

In case you need some help starting this goal, we reached out to our incredible Healthcare IT Today Community to ask — how can healthcare organizations address social determinants of health (SDoH) to reduce disparities and promote health equity in underserved communities? The following are their answers.

Dr. Bernie Saks, Founder and CEO at ful. Health
Healthcare equity starts with financial equity. Today, when people spend their premium dollars on health insurance, they often lose control and transparency in their healthcare choices. By empowering individuals to make informed decisions about their healthcare spending—while still collectively managing resources for major events—we can give consumers back their power. Educating people to be savvy healthcare consumers is key to creating a more equitable system that benefits everyone.

Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company
With so many patients across the nation struggling with social determinants of health (SDoH) challenges, providers will look to do their part to help patients overcome these barriers. For example, providers can help patients experiencing economic insecurity by adopting tools that increase affordability, convenience, and transparency, such as flexible payment plans, pre-service cost estimates, and next-generation payment methods.

Jessica Kral, Chief Information Officer at Modivcare
Traditional healthcare often doesn’t fully support vulnerable patients, especially those with complex needs. A more holistic approach that works with Medicare and Medicaid, can better meet everyday health needs and improve access to care, especially by addressing the social determinants of health. By offering different ways to access care—like transportation, remote monitoring, and home health—patients can get the support they need when and where it works best for them. Access to care can be optimized by effective use of data enabled by technology to provide individualized insights about patient needs, allowing for proactive interventions and better coordination of services. This approach makes healthcare more accessible and equitable for all patients.

Dipak Patel, CEO at GLOBO Language Solutions
Why does health equity matter? First, it’s a fundamental human right that ensures everyone has the opportunity to achieve their full potential for health and well-being. Second, it’s good business, with a high population of healthy people helping to reduce the per capita costs of healthcare. Third, health equity is essential to successfully transition from today’s costly fee-for-service payment model to value-based care, which is based on improving care quality while eliminating unnecessary costs. Health equity is the driving force America needs to elevate its healthcare system to the next level.

Oren Nissim, Co-Founder and CEO at Brook.ai
Beyond traditional remote patient monitoring, remote care management addresses longstanding healthcare inequities by bringing high-quality chronic disease management into underserved communities through culturally competent programs that combine technology with human support. These initiatives extend beyond clinical monitoring to address social determinants of health by integrating community health workers and connecting patients with local resources for nutrition, transportation, and social support. The impact is especially notable in rural and urban underserved areas, where remote monitoring enables local providers to manage complex conditions with specialist support, helping close long-standing disparities in chronic disease outcomes.

Kevin Keenahan, Chief Product Officer at Net Health
With rising debt and declining revenue, rural hospitals face an increased risk of closure or the elimination of inpatient services, further restricting healthcare access for vulnerable rural communities. To address mounting expenses, rural healthcare providers are turning to specialized EHR systems and AI assistants to maximize the efficiency of in-person patient visits. These technologies streamline inpatient and outpatient services, reducing costs for healthcare facilities and patients.

Katherine Seay, Executive Vice President at Clinical Trial Media
Diversity in healthcare needs to extend to every corner of the industry, from healthcare practitioners to the drug development and discovery process. One area where the need for diversity has never been greater is clinical trials.

Although the industry has long understood the need for trials to reflect populations as a whole, accomplishing it presents an ongoing struggle. For instance, in the U.S., Hispanic or Latino people make up 19% of the population, but only 11% of clinical trial participants in 2020 were Hispanic. The historical lack of diversity in trials isn’t due to a lack of desire on behalf of sponsors, nor a lack of interest among diverse populations to participate. Rather, it’s that many people don’t know what trial options are available to them or how to get involved. This means clinical trial recruitment efforts can’t operate as though all potential participants have the same baseline knowledge. That assumption alone has largely contributed to the challenges reaching and resonating with these populations today. Educating underrepresented populations about clinical trials requires getting in front of them first.

Potential participants are often spread across wide geographic locations, with different health conditions and varying levels of knowledge about trials, so sponsors need to meet potential participants where they are. Scaling this type of participant identification effort with precision is a job for technology. Using AI and machine learning-driven platforms allows sponsors to hyper-target media buying and outreach efforts at scale. Geo-specific advertising enables sponsors to find relevant people in the desired physical locations. The next step is making sure that each individual gets the right message–matching their level of familiarity with trials, the information they need to know, and the language that’s most comfortable to them. For example, if a trial is looking to recruit Hispanic participants, there should be a Spanish-language component to outreach. Additionally, having Spanish-speaking nurses on staff at trial sites to communicate with participants in their first language can help boost clinical trial enrollment and retention.

This precision approach to targeting, educating, and moving participants through the trial process has resulted in significant breakthroughs in the levels of diversity we’ve been able to deliver to recent trials. For example, diverse populations accounted for 32% of randomizations into a recent cardiometabolic program, which tests treatment for conditions that most prominently affect American Indians, Alaskan Natives, Black, and Hispanic populations.

Laura Crowell, PhD, Director of R&D at Sunflower Therapeutics
We will not achieve true health equity without addressing barriers to access in the healthcare system, including barriers to the availability of affordable vaccines and biologic medicines. No matter where they live, patients deserve to have access to live-saving vaccines and drugs. Addressing this inequitable access on both a national and a global scale should be top of mind for policymakers. In the US, social determinants such as socioeconomic status and location greatly influence access, and on a global scale, the fact that vaccines and biologic medicines are primarily produced in the Global North creates significant barriers to availability and affordability in the Global South.

Both nationally and globally, healthcare organizations and policymakers must prioritize distributed biologics manufacturing to ensure equitable access to vaccines across demographics and locations. Distributed manufacturing not only facilitates the production and distribution of vaccines to underserved regions, but regional manufacturing can also help ensure a timely and equitable response to emerging local needs for areas with vulnerable populations.

Meghan Harrington, VP Clinical Trial Financial Management at Medidata
Healthcare organizations need to ensure the representation and inclusion of marginalized communities at the onset of the study in order to achieve more equitable delivery of care. Clinical trial diversity is essential for ensuring results are representative, leading to safer and more effective therapies for all patients. While there are many factors that contribute to underrepresentation, compensation for clinical trial participation is significant.

Financial restraints, such as underfunded grant budgets for patient expenses or transportation reimbursements to and from the clinical site, may prevent many from participating in trials. Thus, it’s crucial for researchers to adopt new perspectives on clinical trial participation budgeting practices and adopt technology that supports the control and auditability of these budgets. Lastly, it is important for healthcare organizations to meet the patients where they are in terms of access or trust in the exchange of financial information. By providing flexible payment options, organizations can ensure more equitable access to a broader patient population.

Jennifer Keville, Director Clinical Services at Noridian Healthcare Solutions, LLC
Access to healthcare in rural areas is a critical determinant of overall health. Barriers such as distance, total drive time for patients, and the availability of primary or specialty care providers often hinder access to care in rural communities. While detailed data analysis can identify the number and types of providers available within specific regions or states, distance to beneficiaries, most prevalent co-morbidities, and more, data alone falls short of capturing the nuanced challenges faced by those serving rural populations.

Engaging directly with providers, suppliers, and organizations supporting rural communities—through listening tours or similar initiatives—can validate data and uncover solutions to inform policy changes. Gathering firsthand insights from the rural provider community allows for a deeper understanding of the barriers and challenges that data may not reveal, such as staffing shortages, etc. Building meaningful relationships and collaborating with those working in rural healthcare allows us to combine broader insights with data, enabling more comprehensive strategies to address rural health disparities.

Andrew Speight, Chief Marketing Officer at RXNT
Health equity is a challenge far larger than what healthcare organizations can resolve alone. Working towards true health equity means addressing systemic barriers like gaps in insurance coverage, providing financial flexibility like sliding fee schedules, developing community-based health initiatives like mobile clinics, educational programs, or ride-sharing for patients, and expanding access to telehealth and the broadband infrastructure to support it—particularly for rural patients.

John Weir, Managing Director at BluePath Health
A growing emphasis on interoperability and the inclusion of SDOH data in health systems industry-wide is essential to promote health equity. Organizations are increasingly striving to go beyond traditional electronic health records (EHRs) by integrating other data sources that paint a fuller picture of a patient’s life, which can profoundly improve a care manager’s understanding of the patient and the coordination of care necessary to improve their situation. For instance, understanding a patient’s housing status or food security can influence treatment plans—shifting from prescribing expensive medications to more practical, accessible alternatives.

Saji Rajasekharan, Chief Technology Officer at Experity
Accessibility and technology work hand-in-hand when it comes to addressing social determinants of health. In order to reduce disparities and promote health equity in underserved groups, it is crucial for healthcare services to be widespread and easily accessible to all communities. Urgent care can play a significant role in increasing access to care for areas with limited physician access by providing on-demand care for patients who otherwise would have to wait, or in some cases, not seek care at all. In addition to overall accessibility, evolving technology can have a significant impact on advancing health equity. By better-connecting resources to improve the quality and efficiency of care, it’s supporting the healthcare resources available throughout communities, no matter their location.

Andrea Idusuyi, Manager of Clinical Services at Shields Health Solutions
Despite strides toward improved health equity, barriers remain as social and environmental factors limit access to quality healthcare in underserved communities. Our work shows the first step in improving patient outcomes comes from comprehensive SDOH screenings and intervention protocols, which can identify key non-clinical factors in patient outcomes. By seamlessly integrating SDOH screenings into their care models, standardized assessment tools, electronic health records, and clinical workflows, healthcare organizations can establish a more comprehensive understanding of factors that contribute to patient health and empower patients to take control of their own health and well-being.

So many great answers here! Huge thank you to Dr. Bernie Saks, Founder and CEO at ful. Health, Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company, Jessica Kral, Chief Information Officer at Modivcare, Dipak Patel, CEO at GLOBO Language Solutions, Oren Nissim, Co-Founder and CEO at Brook.ai, Kevin Keenahan, Chief Product Officer at Net Health, Katherine Seay, Executive Vice President at Clinical Trial Media, Laura Crowell, PhD, Director of R&D at Sunflower Therapeutics, Meghan Harrington, VP Clinical Trial Financial Management at Medidata, Jennifer Keville, Director Clinical Services at Noridian Healthcare Solutions, LLC, Andrew Speight, Chief Marketing Officer at RXNT, John Weir, Managing Director at BluePath Health, Saji Rajasekharan, Chief Technology Officer at Experity, and Andrea Idusuyi, Manager of Clinical Services at Shields Health Solutions for taking the time out of your day to submit a quote to us! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.

How do you think healthcare organizations can address social determinants of health (SDoH) to reduce disparities and promote health equity in underserved communities? Let us know over on social media, we’d love to hear from all of you!

The new year is a time for reflection and goal-making. As the year begins, so do our aspirations on how we can improve. In the world of healthcare, one of the biggest improvements we need is health equity. It doesn’t matter how much we improve our services and our technology if only a select few will be able to access it. The only way to truly deliver good healthcare services is through ensuring everyone gets the same level of care in spite of the barriers that may be in the way. So as 2025 begins, let’s all strive to reduce disparities and promote health equity in underserved communities this year!

In case you need some help starting this goal, we reached out to our incredible Healthcare IT Today Community to ask — how can healthcare organizations address social determinants of health (SDoH) to reduce disparities and promote health equity in underserved communities? The following are their answers.

Dr. Bernie Saks, Founder and CEO at ful. Health
Healthcare equity starts with financial equity. Today, when people spend their premium dollars on health insurance, they often lose control and transparency in their healthcare choices. By empowering individuals to make informed decisions about their healthcare spending—while still collectively managing resources for major events—we can give consumers back their power. Educating people to be savvy healthcare consumers is key to creating a more equitable system that benefits everyone.

Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company
With so many patients across the nation struggling with social determinants of health (SDoH) challenges, providers will look to do their part to help patients overcome these barriers. For example, providers can help patients experiencing economic insecurity by adopting tools that increase affordability, convenience, and transparency, such as flexible payment plans, pre-service cost estimates, and next-generation payment methods.

Jessica Kral, Chief Information Officer at Modivcare
Traditional healthcare often doesn’t fully support vulnerable patients, especially those with complex needs. A more holistic approach that works with Medicare and Medicaid, can better meet everyday health needs and improve access to care, especially by addressing the social determinants of health. By offering different ways to access care—like transportation, remote monitoring, and home health—patients can get the support they need when and where it works best for them. Access to care can be optimized by effective use of data enabled by technology to provide individualized insights about patient needs, allowing for proactive interventions and better coordination of services. This approach makes healthcare more accessible and equitable for all patients.

Dipak Patel, CEO at GLOBO Language Solutions
Why does health equity matter? First, it’s a fundamental human right that ensures everyone has the opportunity to achieve their full potential for health and well-being. Second, it’s good business, with a high population of healthy people helping to reduce the per capita costs of healthcare. Third, health equity is essential to successfully transition from today’s costly fee-for-service payment model to value-based care, which is based on improving care quality while eliminating unnecessary costs. Health equity is the driving force America needs to elevate its healthcare system to the next level.

Oren Nissim, Co-Founder and CEO at Brook.ai
Beyond traditional remote patient monitoring, remote care management addresses longstanding healthcare inequities by bringing high-quality chronic disease management into underserved communities through culturally competent programs that combine technology with human support. These initiatives extend beyond clinical monitoring to address social determinants of health by integrating community health workers and connecting patients with local resources for nutrition, transportation, and social support. The impact is especially notable in rural and urban underserved areas, where remote monitoring enables local providers to manage complex conditions with specialist support, helping close long-standing disparities in chronic disease outcomes.

Kevin Keenahan, Chief Product Officer at Net Health
With rising debt and declining revenue, rural hospitals face an increased risk of closure or the elimination of inpatient services, further restricting healthcare access for vulnerable rural communities. To address mounting expenses, rural healthcare providers are turning to specialized EHR systems and AI assistants to maximize the efficiency of in-person patient visits. These technologies streamline inpatient and outpatient services, reducing costs for healthcare facilities and patients.

Katherine Seay, Executive Vice President at Clinical Trial Media
Diversity in healthcare needs to extend to every corner of the industry, from healthcare practitioners to the drug development and discovery process. One area where the need for diversity has never been greater is clinical trials.

Although the industry has long understood the need for trials to reflect populations as a whole, accomplishing it presents an ongoing struggle. For instance, in the U.S., Hispanic or Latino people make up 19% of the population, but only 11% of clinical trial participants in 2020 were Hispanic. The historical lack of diversity in trials isn’t due to a lack of desire on behalf of sponsors, nor a lack of interest among diverse populations to participate. Rather, it’s that many people don’t know what trial options are available to them or how to get involved. This means clinical trial recruitment efforts can’t operate as though all potential participants have the same baseline knowledge. That assumption alone has largely contributed to the challenges reaching and resonating with these populations today. Educating underrepresented populations about clinical trials requires getting in front of them first.

Potential participants are often spread across wide geographic locations, with different health conditions and varying levels of knowledge about trials, so sponsors need to meet potential participants where they are. Scaling this type of participant identification effort with precision is a job for technology. Using AI and machine learning-driven platforms allows sponsors to hyper-target media buying and outreach efforts at scale. Geo-specific advertising enables sponsors to find relevant people in the desired physical locations. The next step is making sure that each individual gets the right message–matching their level of familiarity with trials, the information they need to know, and the language that’s most comfortable to them. For example, if a trial is looking to recruit Hispanic participants, there should be a Spanish-language component to outreach. Additionally, having Spanish-speaking nurses on staff at trial sites to communicate with participants in their first language can help boost clinical trial enrollment and retention.

This precision approach to targeting, educating, and moving participants through the trial process has resulted in significant breakthroughs in the levels of diversity we’ve been able to deliver to recent trials. For example, diverse populations accounted for 32% of randomizations into a recent cardiometabolic program, which tests treatment for conditions that most prominently affect American Indians, Alaskan Natives, Black, and Hispanic populations.

Laura Crowell, PhD, Director of R&D at Sunflower Therapeutics
We will not achieve true health equity without addressing barriers to access in the healthcare system, including barriers to the availability of affordable vaccines and biologic medicines. No matter where they live, patients deserve to have access to live-saving vaccines and drugs. Addressing this inequitable access on both a national and a global scale should be top of mind for policymakers. In the US, social determinants such as socioeconomic status and location greatly influence access, and on a global scale, the fact that vaccines and biologic medicines are primarily produced in the Global North creates significant barriers to availability and affordability in the Global South.

Both nationally and globally, healthcare organizations and policymakers must prioritize distributed biologics manufacturing to ensure equitable access to vaccines across demographics and locations. Distributed manufacturing not only facilitates the production and distribution of vaccines to underserved regions, but regional manufacturing can also help ensure a timely and equitable response to emerging local needs for areas with vulnerable populations.

Meghan Harrington, VP Clinical Trial Financial Management at Medidata
Healthcare organizations need to ensure the representation and inclusion of marginalized communities at the onset of the study in order to achieve more equitable delivery of care. Clinical trial diversity is essential for ensuring results are representative, leading to safer and more effective therapies for all patients. While there are many factors that contribute to underrepresentation, compensation for clinical trial participation is significant.

Financial restraints, such as underfunded grant budgets for patient expenses or transportation reimbursements to and from the clinical site, may prevent many from participating in trials. Thus, it’s crucial for researchers to adopt new perspectives on clinical trial participation budgeting practices and adopt technology that supports the control and auditability of these budgets. Lastly, it is important for healthcare organizations to meet the patients where they are in terms of access or trust in the exchange of financial information. By providing flexible payment options, organizations can ensure more equitable access to a broader patient population.

Jennifer Keville, Director Clinical Services at Noridian Healthcare Solutions, LLC
Access to healthcare in rural areas is a critical determinant of overall health. Barriers such as distance, total drive time for patients, and the availability of primary or specialty care providers often hinder access to care in rural communities. While detailed data analysis can identify the number and types of providers available within specific regions or states, distance to beneficiaries, most prevalent co-morbidities, and more, data alone falls short of capturing the nuanced challenges faced by those serving rural populations.

Engaging directly with providers, suppliers, and organizations supporting rural communities—through listening tours or similar initiatives—can validate data and uncover solutions to inform policy changes. Gathering firsthand insights from the rural provider community allows for a deeper understanding of the barriers and challenges that data may not reveal, such as staffing shortages, etc. Building meaningful relationships and collaborating with those working in rural healthcare allows us to combine broader insights with data, enabling more comprehensive strategies to address rural health disparities.

Andrew Speight, Chief Marketing Officer at RXNT
Health equity is a challenge far larger than what healthcare organizations can resolve alone. Working towards true health equity means addressing systemic barriers like gaps in insurance coverage, providing financial flexibility like sliding fee schedules, developing community-based health initiatives like mobile clinics, educational programs, or ride-sharing for patients, and expanding access to telehealth and the broadband infrastructure to support it—particularly for rural patients.

John Weir, Managing Director at BluePath Health
A growing emphasis on interoperability and the inclusion of SDOH data in health systems industry-wide is essential to promote health equity. Organizations are increasingly striving to go beyond traditional electronic health records (EHRs) by integrating other data sources that paint a fuller picture of a patient’s life, which can profoundly improve a care manager’s understanding of the patient and the coordination of care necessary to improve their situation. For instance, understanding a patient’s housing status or food security can influence treatment plans—shifting from prescribing expensive medications to more practical, accessible alternatives.

Saji Rajasekharan, Chief Technology Officer at Experity
Accessibility and technology work hand-in-hand when it comes to addressing social determinants of health. In order to reduce disparities and promote health equity in underserved groups, it is crucial for healthcare services to be widespread and easily accessible to all communities. Urgent care can play a significant role in increasing access to care for areas with limited physician access by providing on-demand care for patients who otherwise would have to wait, or in some cases, not seek care at all. In addition to overall accessibility, evolving technology can have a significant impact on advancing health equity. By better-connecting resources to improve the quality and efficiency of care, it’s supporting the healthcare resources available throughout communities, no matter their location.

Andrea Idusuyi, Manager of Clinical Services at Shields Health Solutions
Despite strides toward improved health equity, barriers remain as social and environmental factors limit access to quality healthcare in underserved communities. Our work shows the first step in improving patient outcomes comes from comprehensive SDOH screenings and intervention protocols, which can identify key non-clinical factors in patient outcomes. By seamlessly integrating SDOH screenings into their care models, standardized assessment tools, electronic health records, and clinical workflows, healthcare organizations can establish a more comprehensive understanding of factors that contribute to patient health and empower patients to take control of their own health and well-being.

So many great answers here! Huge thank you to Dr. Bernie Saks, Founder and CEO at ful. Health, Ryne Natzke, Chief Revenue Officer at TrustCommerce, a Sphere Company, Jessica Kral, Chief Information Officer at Modivcare, Dipak Patel, CEO at GLOBO Language Solutions, Oren Nissim, Co-Founder and CEO at Brook.ai, Kevin Keenahan, Chief Product Officer at Net Health, Katherine Seay, Executive Vice President at Clinical Trial Media, Laura Crowell, PhD, Director of R&D at Sunflower Therapeutics, Meghan Harrington, VP Clinical Trial Financial Management at Medidata, Jennifer Keville, Director Clinical Services at Noridian Healthcare Solutions, LLC, Andrew Speight, Chief Marketing Officer at RXNT, John Weir, Managing Director at BluePath Health, Saji Rajasekharan, Chief Technology Officer at Experity, and Andrea Idusuyi, Manager of Clinical Services at Shields Health Solutions for taking the time out of your day to submit a quote to us! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.

How do you think healthcare organizations can address social determinants of health (SDoH) to reduce disparities and promote health equity in underserved communities? Let us know over on social media, we’d love to hear from all of you!