Finding Effective Ways To Address Social Determinants Of Health - Health Affairs

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It has become a truism in the worlds of health care and public health that direct medical care accounts for only a small part of our actual health status. Even the best medical care, on average, will extend and improve our lives less than the combined benefits of nutritious foods, access to places to be physically active, safe and healthy homes, good air quality, lack of chronic stress, social support, and other aspects of what are sometimes called the “social determinants of health.” As much as 80 percent of the factors that influence our health, it turns out, operate outside the walls of the hospital or clinic.

We know this, but the way we spend our money as a society doesn’t reflect it. Instead of prioritizing the social determinants of health (SDOH) and preventive health strategies to improve overall population health, we prefer to wait until people are sick and then respond with expensive medical care. As a result, the United States spends more on health care than the rest of the developed world, but our outcomes are mediocre at best. We live shorter, unhealthier lives than we could be living.

It doesn’t have to be this way. We can be smarter, healthier, more efficient, and more equal. And the health care and public health sectors have a role to play in moving us toward achieving those goals. One essential approach being used around the United States is to better integrate health care with the social services sector, so that when people encounter either realm, they’ll get more of their needs met in the other realm as well.

Examples Of SDOH Integration Efforts In Texas

In Texas a range of organizations that include several Episcopal Health Foundation grantees are already working to achieve this integration. St. Paul Children’s Medical Clinic is an independent clinic in Tyler, Texas, that provides pediatric medical and dental care for kids, from birth all the way to age 21. It screens all of its patients for social needs, runs both a food bank and a clothes closet as part of its operations, and assists clients in obtaining and enrolling in external social services.

In Houston the Baylor College of Medicine’s Environmental Health Service works directly with patients to reduce the environmental contributors—in their homes—to asthma. The services include a comprehensive asthma assessment, tailored asthma self-management education, and home visits to identify and reduce indoor allergens.

In Austin the Texas Legal Services Center Medical-Legal Partnership embeds legal professionals at People’s Community Clinic, a network of federally qualified health centers (FQHCs). Patients are given legal assistance with needs related to housing, immigration, financial security, and other “health-harming” needs in the same place they get their health care, and in coordination with that care.

And in the Alvin, Texas, area, the Stephen F. Austin Community Health Network has collaborated with the United Way of Brazoria County and its network of social services providers to establish a shared, online, secure community resource referral platform. This platform allows all partners to identify available resources, make referrals, track services, and create accountability. In addition to meeting patients’ social needs, the community clinic’s system is assessing the health impacts of receiving those social services, specifically among its diabetic patients.

A recent report from the Texas Health Improvement Network, funded by Episcopal Health Foundation, surveyed these and other efforts to both understand what’s being implemented and make recommendations for future projects. The report, Addressing Social Needs Through Integrated Healthcare and Social Care in Texas: Case Studies, Key Issues, and Recommendations to Advance Practice, zeroed in on a few key strategies for success.

Suggested Strategies

Technology is key. Technology that is integrated across health and social services systems is optimal. There are a number of good platforms available that enable health care organizations to systematically screen their patients for social needs and identify potential resources for them in their community. These are a good start, but the goal should be to integrate such software both with internal electronic health records and with databases and systems on the social-sector side of things. This will enable more effective hand-offs between the sectors, better tracking of outcomes, and more coordination between health care and social services organizations.

More coordination will enable better outcomes. Unsurprisingly, many of the most effective integrations involve organizations that provide both health and social services themselves. Such “all-in-one” organizations are the exception, though. In most cases, the more realistic opportunities arise from closer coordination among multiple organizations. These can involve connecting referral systems; forming “umbrella” coalitions, which bring together stakeholders from across multiple sectors around a common goal; and convening workgroups focused on integration.

The evidence base needs to grow. It’s one thing to document that the effects of SDOH are immensely important to our lives and health. It’s a very different thing to develop and then document effective strategies for addressing SDOH.

The questions we need to answer include:

What are the most effective and cost effective interventions and strategies?
For those interventions that do work, how are they achieving their effects?
Is it more effective (and cost effective) to target certain social risks rather than others?
Do social needs interventions have negative unintended consequences?
What are the impacts on health equity?
And which payment and quality incentives can drive adoption of interventions?

Until we can deepen this evidence base, and sift out what works and how, we can’t expect big organizations, systems, and, above all, payers to shift resources toward funding integration. The “holy grail” will be evidence of interventions that don’t just reduce health care costs, but reduce them for the organizations that are funding the interventions. Many payers are experimenting with ways to address or cover costs related to patients’ social needs, but to justify and expand the investment, they need to be able to achieve cost savings in a relatively short timeframe.

Finally, funders from all sectors need to take some thoughtful risks to move us forward. Right now we’re in a gap period. We have good reason to believe that integration of health and social care will improve health and reduce overall costs, but we haven’t yet figured out the best interventions, nor how to structure the incentives so that the groups that fund programs will recoup the benefits of them.

To get us to the other side of this gap, we need a wide range of funders—including philanthropy, state legislatures, and health care payers—to provide start-up funds so that communities can build multisector networks and researchers can gather evidence related to implementation, effectiveness, and cost-effectiveness of various integration approaches.

Conclusion

We’re going to get there. The questions are how long it will take us, and how many lives we could save and improve by moving faster rather than slower.