The social determinants of health play a larger role in determining overall health than does clinical care. Health care organizations, particularly those serving low-income or otherwise vulnerable populations have a significant opportunity to improve the health of their patients and members, and their own bottom lines, by developing and implementing strategies for addressing the social determinants of health. Although it will take leadership and resources, and falls outside the traditional expertise of health care organizations, developing and implementing strategies for addressing the social determinants of health can be relatively straightforward.
The Social Determinants of Health
By now, the awareness of the role that social and environmental factors play in affecting overall health has become well-established. One popular analysis supporting this conclusion comes from the County Health Rankings, an annual “population health check-up” produced by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation. According to that analysis, 40% of health outcomes are driven by social and economic factors whereas only 20% of health outcomes are driven by clinical care. (Health behaviors and the physical environment contribute 30% and 10%, respectively.) The County Health Rankings describes these social and economic factors, often referred to as the social determinants of health, to include education, employment, income, family and social support, and community safety. Other factors sometimes included among the social determinants of health include access to food, housing and transportation. (While some people do not like the fatalistic implication behind the word ‘determinants’, the health care and health policy communities have clearly converged on the term, so that is what I will use.)
The Social Determinants Imperative
The United States spends far more as a percentage of GDP (Exhibit 1) on health care than other developed countries, but far less on social programs (Exhibit 8). However, its spending on health care and social programs combined puts it squarely in the middle of the pack (Exhibit 8). While it is well recognized that price is one of the most significant drivers of high U.S. health care spending relative to other developed countries (a topic that will be discussed in a forthcoming article), it appears likely that low relative spending on social programs plays a role as well. Recent research on relative spending on social services, public health, and health care across states supports this interpretation.
Health care organizations with revenue models that reward lower health care costs and better long-term health outcomes are microcosms of this phenomenon. In particular, hospitals serving high numbers of uninsured patients (charity hospitals), and health plans operating in the Medicaid and Medicare programs (public health plans) would benefit from developing and implementing strategies for addressing the social determinants of health. If charity hospitals can keep their uninsured patients healthier and out of their emergency departments and inpatient beds, then the hospitals will not incur the direct resource costs associated with treating those individuals and will be able to keep beds available for paying patients. If public health plans can bring social services to bear for their members in ways that address the social determinants of health, thus keeping their members healthier, then they stand to gain directly by keeping more of the premium dollars that they receive. For neither charity hospitals nor public health plans does this situation justify open-ended or unfocused spending on social services. However, with the appropriate targeting, investment in social services can have a positive impact on their bottom lines. In addition, providing health care professionals with tools for addressing the social determinants of health may help to prevent burnout.
Health Care Organizations Addressing the Social Determinants
There are examples of forward-thinking health care organizations already developing and implementing programs for addressing the social determinants of health. Some such efforts address issues relating to food, such as food insecurity or bad eating habits. One program in New Orleans teaches cooking classes to patients with congestive heart failure. Another program, through a program administered by the health insurer Anthem, home-delivers meals to members recently discharged from the hospital. In some cases, hospitals have developed distribution channels for fresh produce and other healthy food, and have even planted large gardens to provide opportunities to address the food insecurity of some of their patients.
Housing is another social determinant of health on which some organizations are starting to focus. Through one government program, chronically homeless individuals were provided with housing, resulting in lower public health care spending. In another case, a hospital paid rent for some of its most frequent uninsured emergency department visitors, which reduced the frequency with which they visited the emergency department significantly. While some individuals may not be experiencing housing insecurity, other aspects of their home situation may be preventing them from healing or remaining healthy in their own home. There is evidence that scrubbing homes of allergens may improve pediatric asthma outcomes. For older patients, getting direct support with basic activities of daily living after a visit to an emergency department may allow them to be released to heal in their own home rather than being admitted to the hospital.
Technical and Operational Components of a Social Needs Strategy
There are several key technical and operational components that are essential to an effective strategy for addressing the social determinants of health, including a social needs assessment, community resource directory, and referral management process. First, the patient/member should be assessed to identify the presence of any social needs. Fortunately, there are a number of good social needs assessments that have been developed by public and private organizations, including the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), recently developed by the National Association of Community Health Centers. The second key technical/administrative component of a social needs strategy is a searchable and categorized community resource directory listing all of the community resources potentially available to patients/members, including any eligibility criteria. Finally, a social needs strategy for a health care organization needs the technical and administrative capacity for referring patients/members to community resources and monitoring the status of those referrals. In addition, in order to be effective, the social needs strategy must be technically integrated into the organization’s case management system and operationally integrated into the organization’s discharge planning and/or case management processes.
There are several companies that have developed products/services that address some or all of these requirements. I have had the good fortune to work with the market leader in this space, Aunt Bertha (the actual company name; they say: “Aunt Bertha picks up where Uncle Sam leaves off”). Aunt Bertha has developed a web-based social services search platform for helping to connect low-income individuals with community resources for addressing the social determinants of health. Aunt Bertha currently works with six of the eight largest health plans in the country as well as many hospitals, smaller health plans, and other health care organizations. The Aunt Bertha platform automates the social needs assessment (which can be loaded with multiple different assessments) and has a nationwide community resource directory that is constantly being refreshed (which can be augmented with customer listings). It also includes electronic, closed-loop referral management and can technically integrate into case management systems.
Strategic Considerations for a Social Needs Strategy
In addition to implementing the technical and administrative components of a social needs strategy, a health care organization also needs to make some decisions about how broadly the organization will deploy its social needs strategy. While a social needs strategy can be deployed for all patients/members by using community resources not funded by the health care organization, for some subsets of the patient/member population, the health care organization may find it worthwhile to directly fund certain social interventions. These strategies are not mutually exclusive – a health care organization could implement a social needs strategy using community resources for all patients/members and, in addition, services funded by the health care organization for certain patients/members. While many aspects of both the broadly and narrowly targeted strategies are the same, additional steps will need to be taken for a narrowly tailored strategy.
A broadly targeted social needs strategy should include a social needs assessment for all members, connected to a community resource directory through which specific community resources can be identified, referral to the identified community resources, and incorporation of the referrals into the case management system for follow-up. A narrowly tailored social needs strategy should include all of those elements, but will also require identification of particular high-utilizing or high-risk patients/members, identification of potentially cost-effective social interventions, and development of a network of providers who can deliver the identified social interventions in cases where community resources are not available.
Although there is undoubtedly a certain amount of hype around the social determinants of health, there’s also a strong and growing body of evidence that social factors play a significant role in health care spending and overall health. Some forward-thinking health care organizations are already starting to implement strategies for addressing the social determinants of health, in some cases referring patients/members to community resources, in other cases actually paying for social interventions. Increasingly, certain types of health care organizations, particularly charity hospitals and public health plans, will not be able to compete, or will lose money because of their failure to develop strategies for addressing the social determinants of health. Although such strategies may be outside of health care organizations’ traditional areas of expertise, developing them can be straightforward if adequate resources and expertise are brought to bear.