Neftaly: Integrating Social Determinants of Health (SDOH) in Care Planning
Overview
Health is shaped by more than clinical care. Social and environmental conditions — known as Social Determinants of Health (SDOH) — play a critical role in a person’s well-being, influencing everything from disease risk to access to treatment and recovery outcomes. At Neftaly, we believe effective care planning must address the full context of a patient’s life.
Our approach to integrating SDOH into care planning is designed to empower healthcare providers, systems, and communities to create holistic, person-centered interventions that promote health equity and improved outcomes.
What Are Social Determinants of Health?
Social Determinants of Health are the non-medical factors that influence health outcomes. They include:
- Economic Stability: Income, employment, debt, and housing costs
- Education Access and Quality: Literacy, early childhood education, language barriers
- Healthcare Access and Quality: Insurance, provider availability, cultural competency
- Neighborhood and Built Environment: Housing, safety, transportation, pollution
- Social and Community Context: Discrimination, social support, community engagement
Why SDOH Matter in Care Planning
- Up to 80% of health outcomes are influenced by social, behavioral, and environmental factors.
- Ignoring SDOH can lead to misaligned care plans, poor adherence, and preventable readmissions.
- Addressing SDOH promotes health equity, reduces costs, and improves long-term outcomes.
Neftaly’s Approach to SDOH in Care Planning
1. Assessment and Screening
We equip providers with evidence-based tools to identify SDOH needs during intake or follow-up visits.
- Use of standardized SDOH screening tools (e.g., PRAPARE, AHC HRSN)
- Patient interviews and digital self-assessments
- Integration into Electronic Health Records (EHRs)
2. Individualized Care Planning
SDOH data is used to develop care plans that reflect the real-life challenges and resources of each patient.
- Tailoring follow-up appointments based on transportation access
- Connecting food-insecure patients to nutrition support programs
- Adjusting treatment plans for patients facing housing instability
3. Cross-Sector Collaboration
Neftaly promotes collaboration with community-based organizations, government services, and non-clinical partners to meet identified needs.
- Referrals to housing, legal, food, or employment services
- Coordination with schools, shelters, and social services
- Shared care plans that include both clinical and social interventions
4. Training and Capacity Building
We provide training for healthcare teams to recognize and respond to SDOH:
- Cultural competence and trauma-informed care workshops
- Communication skills for discussing sensitive social topics
- Training in equity-driven care coordination
5. Monitoring and Evaluation
We track and measure the impact of addressing SDOH on health outcomes and care efficiency.
- Reduced hospital readmissions and emergency visits
- Improved patient satisfaction and engagement
- Enhanced continuity of care and community trust
Real-World Application: Neftaly in Action
Case Study Example
A diabetic patient repeatedly misses appointments due to unreliable transportation. Through SDOH screening, Neftaly staff identify the barrier, adjust appointment scheduling, and partner with a local transport service to ensure access. The patient’s blood sugar levels stabilize, and their risk of hospitalization drops significantly.
Benefits of SDOH Integration
- Improved patient outcomes and quality of life
- Reduction in avoidable healthcare costs
- Stronger provider-patient relationships
- Enhanced care team coordination
- Advancement toward health equity
Who We Support
Neftaly’s SDOH care planning framework is ideal for:
- Primary care clinics and hospitals
- Public health agencies
- Home health and community care programs
- Managed care organizations
- Non-profits and community health workers
Partner with Neftaly
We invite healthcare systems, policy leaders, educators, and community partners to collaborate in building a care model that treats people, not just symptoms.
✅ Implement SDOH screening tools
✅ Train staff and care teams
✅ Build referral networks
✅ Monitor impact and outcomes
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Conclusion
Addressing social determinants is not an add-on — it’s essential. Neftaly empowers health professionals to design care plans that are realistic, respectful, and responsive to the social realities of each patient.