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Choosing the Right Approach to Social Determinants of Health

When it comes to addressing social determinants of health, care coordination for low-income or geriatric members and nutrition education top the investments made by payers and providers, according to a survey conducted for Envolve Health by Modern Healthcare Custom Media. But are these the right areas for investment?

The answer depends largely on the population being targeted and the communities served, experts say.

“There’s not a magical strategy that is going to work for every community in the United States,” says Rashi Venkataraman, executive director of prevention and population health, America’s Health Insurance Plans (AHIP). “So while the definition of social determinants of health might be the same, as you move from Topeka to New York City to Des Moines, each community has its own challenges.”

From Theory to Strategy

Both payers and providers are deploying a wide range of strategies to address social determinants of health, including substance abuse support, transportation to and from medical appointments, and prenatal education, according to the survey.

Types of programs organizations are employing to address social determinants of health

For the majority of the 600 payers and providers who responded to the survey, their organization’s top focus is on addressing the impact of social determinants of health on members’ ability to manage chronic conditions (50 percent) and behavioral health (20 percent).

Respondents view social issues such as income and income distribution, addiction, lack of family structure/support, health literacy, and access to care as those that most affect members’ health conditions.

These answers surprised some experts. For example, access to healthy food and safe and reliable housing are two of the top social issues impacting Medicaid patients’ health outcomes, according to Francis Rienzo, vice president of advocacy and government relations and interim CEO for Medicaid Health Plans of America (MHPA), yet survey respondents ranked them ninth and 10th, respectively. Meanwhile, social exclusion ranked 14th among the top social issues impacting members’ health outcomes, yet recent research highlights the impact of social exclusion on members’ mental health and mortality rates from conditions such as cardiovascular disease, respiratory disease, cancer, and asthma.1

Other responses to the survey suggest providers and payers are addressing issues that are more directly related to provision of care rather than broader social issues. “That sort of misses the point in that these are not social determinants of healthcare; they’re social determinants of health,” says Matthew W. Kreuter, PhD, MPH, faculty director for the Envolve Center for Health Behavior Change, a research collaboration between Brown School at Washington University in St. Louis, The Center for Advanced Hindsight at Duke University and Centene Corporation.

Why is there so much variation in payer and provider investments in and prioritization of social determinants of health? Recent research suggests it may be because payer and provider efforts to address social determinants are still a relatively new phenomenon. While 88 percent of hospitals say they screen for social needs, screenings aren’t applied consistently, even among target populations.2

Limited access to data around social determinants also gives providers a narrow view of the social issues most affecting their communities. So do budgetary constraints and lack of reimbursement, according to 55 percent of survey respondents.

“I think you’re going to see more progress around addressing social determinants of health in the next couple of years. But right now, these initiatives are tough to implement because the openness to innovation is somewhat limited,” Rienzo says.

New programs organizations would like to administer in the future

Designing a Social Determinants of Health Strategy

How can payers and providers more effectively address social determinants of health? Here are four strategies to consider.

  • Educate team members on social determinants of health. Addressing the social issues that most impact members’ health must start with a common understanding of what social determinants of health means. The World Health Organization defines social determinants of health as “the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life.” This common understanding is vitally important to prioritizing social determinants initiatives. For example, while nutrition education—a social determinants of health strategy deployed by 56 percent of respondents—can help members make healthy food choices, if members live in a food desert and lack access to nutritional foods, the priority should be on providing access to healthy food rather than education.
  • Take a 360-degree view of the social issues impacting your population. Collaborate with payers, providers, and community service organizations to access a broad range of data around social determinants of health, and work with these entities to:
    • Identify which social determinants of health have the greatest impact on member outcomes
    • Determine the right approach for investment
    • Measure the effectiveness of targeted interventions

“Healthcare is really moving toward a whole-person approach to care, and the way in which organizations address social determinants of health should reflect this broader view,” Rienzo says. “It’s not just about doing the smart thing for the populations you manage; it’s about doing the right thing.”

  • Incorporate social supports into clinical models. Look for innovative ways to partner with local resources in addressing gaps in basic needs, such as transportation, safe housing, prenatal assistance, and child care for parents who work. In some communities, physicians are able to “prescribe” assistance from local agencies to address social issues that most impact a member’s health.3
  • Be mindful of resource limitations. Be careful not to duplicate existing efforts, given the lack of funding and staffing available. “In making investments around social determinants of health, it’s important to consider changeability: How likely is it that your efforts will result in positive change for a specific population?” Kreuter says. “For example, safe and reliable housing is important to people’s health, but it’s difficult—and costly—to make a substantial impact on housing resources in your community.”

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Sources: 1“Social Exclusion Heightens Risk of Death Across Many Health Conditions,” National Institute for Health Research, Jan. 31, 2018. 2Social Determinants of Health: How Are Hospitals and Health Systems Investing in and Addressing Social Needs? Deloitte, 2017. 3Bachrach, D., Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment, The Commonwealth Fund, May 29, 2014.