As our health system moves toward value-based models which incentivize positive results rather than individual procedures and treatments, healthcare industry leaders increasingly are regarding the social determinants of health (SDOH) as critical components of these efforts. By concentrating on these facets of well-being in tandem with medical care, providers are taking a holistic view of patients and overall population health to enhance patient care, promote superior outcomes, and drive value in healthcare organizations.
What Are the Social Determinants of Health?
SDOH are the complex circumstances in which individuals are born and live that impact their health. They include intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.
The World Health Organization (WHO) offers this definition of social determinants of health: “The conditions in which people are born, grow, live, work and age.” The organization further states that “these circumstances are shaped by the distribution of money, power, and resources at global, national and local levels.” These social circumstances create societal stratification and are responsible for health inequities among different groups of people based on social and economic class, gender, and ethnicity. Social determinants of health are an underlying cause of today’s major societal health dilemmas including obesity, heart disease, diabetes, and depression. Moreover, complex interactions and feedback loops exist among the social determinants of health. For example, poor health or lack of education can impact employment opportunities which in turn constrain income. Low income reduces access to healthcare and nutritious food and increases hardship. Hardship causes stress which in turn promotes unhealthy coping mechanisms such as substance abuse and overeating of unhealthy foods.
Examples of Social Determinants of Health
The social determinants of health are a subset of determinants of health. Governmental policies, availability of healthcare, individual behavioral choices, and biological and genetic factors are other notable determinants of health. Examples of social determinants of health include:
- Income level
- Educational opportunities
- Occupation, employment status, and workplace safety
- Gender inequity
- Racial segregation
- Food insecurity and inaccessibility of nutritious food choices
- Access to housing and utility services
- Early childhood experiences and development
- Social support and community inclusivity
- Crime rates and exposure to violent behavior
- Availability of transportation
- Neighborhood conditions and physical environment
- Access to safe drinking water, clean air, and toxin-free environments
- Recreational and leisure opportunities
How Are Healthcare Leaders Addressing the Social Determinants of Health?
Since the ACA began moving healthcare from fee-based compensation to outcome-based compensation and expanded access to millions of high-risk Americans previously sidelined from preventative and primary care, healthcare leaders have been progressively shifting toward increasing health equity and addressing the paradigm shift towards population health by attending to the social determinants of health.
Indeed, healthcare leaders are increasingly aware of the data and research which indicates that the social determinants of health have a higher impact on population health than healthcare and that a higher ratio of social service spending versus healthcare spending results in improved population health. In fact, according to a study published by the National Center for Biotechnology Information, states that allocate more resources to social services than to medical expenditures have substantially improved health outcomes over states that do not. The study found that states that provide higher levels of social services are outperforming their counterparts in areas such as obesity, asthma, mental health, cancer, myocardial infarction, and type 2 diabetes.
In tackling the social determinants of health, providers are partnering with community organizations to improve access to housing, healthy food, education, job training, transportation and more. Countless initiatives are underway. Here, we highlight two inspiring examples.
Collaborative Care Teams and Authentic Healing Relationships
In the high-poverty city of Camden, New Jersey, residents have struggled to access services for behavioral, social, and medical care and consequently end up in emergency rooms instead. To counter this problem, the Camden Coalition of Healthcare Providers are using data to identify frequent consumers of emergency care and then connect them to a team of primary care providers, nurses, social workers, and behavioral health specialists. These care providers develop “authentic healing relationships” with patients to address their complicated health needs and social requirements through proactive primary care and social services rather than costly emergency department visits. According to Camden Coalition’s coach manual, “The Authentic Healing Relationship is a respectful, trusting and non-judgmental partnership between the Care Team and the patient that serves as the foundation for progress toward long-term health management.” The team strives to empower patients to take ownership of their health and help them to build support networks through community organizations as well as friends and family.
Healthy Neighborhoods Healthy Families
One of the most inspirational and far-reaching provider-based programs developed to provide SDOH solutions is Nationwide Children’s Hospital’s Healthy Neighborhoods Healthy Families (HNHF) initiative. Nationwide Children’s has partnered with multiple community partners to tackle five high-impact social determinants: affordable housing, education, health and wellness, safe and accessible neighborhoods, and workforce development. To promote access to affordable housing, they have partnered with Healthy Homes to revitalize local communities through renovation, energy efficiency and green living projects, and repair and maintenance grants to homeowners. They also offer low-income housing to families where residents can participate in on-site classes that provide training targeted toward local job openings and career success skills. They are also tackling challenges in education with kindergarten readiness, mentoring, and STEM programs. Along with the Ronald McDonald House, they have created a mobile care center to provide pediatric primary care including immunizations, developmental screenings, teen health education, and well-child and sick visits. These are just a few of Nationwide Children’s SDOH ambitious undertakings.
PRAPARE: Assessing Social Determinants of Health in Your Patient Population
An important first step providers can take is to learn about the population health of the communities they serve. One resource for doing so is the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) from the National Association of Community Health Centers (NACHC). PRAPARE provides an implementation and action toolkit that is being used by providers nation-wide to gather data that will allow them to assess their patients’ social needs, so they can take measures to address them. Their evaluation tool asks social health questions in areas ranging from demographic data and housing status to social-emotional health and physical security. Another key resource for providers is Health Lead’s Social Needs Screening Toolkit. Health Leads, a trailblazer in the movement to address the social determinants of health, created this kit to help healthcare leaders develop an assessment tailored to their population needs.
Social and Moral Imperative
More and more, healthcare leaders are positioning their organizations to assume the social and moral imperative of reducing health inequity by focusing on the social determinants of health. Through creative partnerships, new care delivery models, and population health assessment, they are innovating to improve the health and quality of life of their community’s most vulnerable residents. Healthcare leaders recognize that it is vital to reform the system, so it is sustainable and accessible for all. Moreover, they understand that the social determinants of health are significant factors in this invaluable endeavor.