In a previous article, I provided some background on the social determinants of health, made the case that most health care organizations, particularly those with low-income or elderly members or patients, would benefit from a well-thought-out social needs strategy, and described some of the general contours of such a strategy. In this article, I lay out a high-level roadmap that health care organizations can use to develop and implement an impactful social needs strategy.
The roadmap for developing and implementing a social needs strategy is structured around four primary phases – identifying the unmet social needs in the community, assessing the organization’s existing approach to addressing social needs, developing an intentional social needs strategy, and planning for the implementation of the strategy. While most health care organizations will likely benefit from an intentional and informed social needs strategy, certain health care organizations such as charity hospitals (i.e., public and nonprofit hospitals) and public health plans (i.e., Medicaid managed care organizations and Medicare Advantage plans) will benefit disproportionately due to the socio-economic character of their patients and members, respectively. (In this article, ‘health care organization’ is intended to include large health care providers, primarily hospitals, as well as health insurance companies. While some smaller provider organizations such as physician groups may benefit from a social needs strategy, it is not as much of a strategic imperative.)
Phase 1: Community Social Vulnerability Assessment
In the first phase of the roadmap, the health care organization should identify the scale and composition of unmet social needs among its members or patients. A good first step is to conduct a community social needs review by either reviewing existing demographic and socio-economic data to estimate social needs or conducting a survey to directly measure social needs. Once the health care organization understands the social needs of its members or patients, it should seek to understand what resources are available in the community to potentially meet those needs. The health care organization can review community resource directories maintained by stakeholders or perform searches for common types of community resources in free community resource directories. Once the health care organization understands both the community’s social needs and the resources available in the community for addressing those needs, any remaining gap between the supply of, and demand for community resources should become apparent.
(Some health care organizations, particularly non-profit and public hospitals, will have conducted a community health needs assessment of community health assessment recently. While these existing assessments may include social needs and be useful as part of the community social vulnerability assessment, they typically focus on health status and disease incidence rather than social needs and will likely need to be supplemented.)
Phase 2: Organizational Social Needs Strategy Assessment
The second phase of the roadmap is for the health care organization to determine how, if at all, it currently attempts to identify and address social needs among its members or patients. As with the community social vulnerability assessment, the organizational social needs strategy assessment is essentially a gap analysis, but in this case the gap being analyzed is between the organization’s current approach to identifying and addressing social needs and the incidence of pathologies that might be sensitive to social factors. A structured self-assessment questionnaire and interviews with key employees and partners will inform the understanding of the organization’s current approach to addressing its members’ or patients’ social needs. Through analysis of medical or claims records, the organization should be able to determine what proportion of their population has conditions that are likely to benefit from social interventions.
Phase 3: Social Needs Strategy Development
The third and most significant phase of the roadmap is the development of the social needs strategy. First, the health care organization should decide whether the social needs strategy should focus on its whole population, or only a subset, or have different components of the strategy for different groups. For example, a Medicaid managed care organization might observe from its analysis of claims data that its members with diabetes tend to have higher costs later in the month and hypothesize that their nutrition suffers when their food stamps run out toward the end of the month, leading them to have greater difficulty controlling their blood sugar and more medical needs. With such an observation, the Medicaid managed care organization might decide to have a focused component of its social needs strategy for its diabetic members and a broader component of its social needs strategy for the rest of its members. In cases such as this, there will likely be an obvious social need that would need to be assessed and addressed. In other cases, particularly when considering a broader population, a social needs assessment should be used to identify the social needs of the individuals in the population, and then the organization could refer to social interventions aligning with those needs.
Health care organizations have traditionally relied on social services provided by community-based organizations such as food pantries, but in some cases, particularly for targeted populations, it may be worthwhile for a health care organization to pay for social services. The particular cases where health care organizations might find it beneficial to pay for social services will vary depending on the health care organization. Facing penalties from Medicare for high readmission levels, hospitals providing lots of Medicare services might find it financially efficient to pay for social interventions that have the potential to reduce readmissions, such as home modifications to reduce fall risk. Medicaid managed care organizations should be willing to pay for any social interventions that are shown to reduce health care costs. At the point when a health care organization decides that it wants to start paying for some social interventions, it will need to develop a network of social service providers, establish contracts for the delivery of those services, and develop policies and procedures for determining when to purchase the social interventions.
Phase 4: Social Needs Strategy Implementation Planning
The fourth phase of the roadmap is planning the implementation of the social needs strategy. First, the health care organization should document existing workflows relating to social needs assessment and social services referral. Then, key employees who will be responsible for performing the assessments, making referrals, and following-up on referrals should be identified. If technical solutions for performing the social needs assessment, searching for community resources, and making and managing referrals are not yet in place, then they will need to be identified. The health care organization should then identify new business processes associated with the social needs strategy and create training materials for the key employees that describe the new workflows and technical solutions. Finally, the health care organization should develop an overall implementation project plan and internal communications materials for explaining the new program to employees and key stakeholders.
Of course, it’s not good enough to do all of that planning all the way through to developing the implementation project plan and communications materials. The plan must be executed, the program must be established, and the health care organization should develop a mechanism for ongoing monitoring of the program to ensure that it is accomplishing its goals.
Health care organizations providing care or managing services for low income individuals are starting to realize that they cannot maximize their impact on the overall health of their members or patients without considering their social needs as well. At the same time, a small but rapidly growing body of evidence supports the idea that certain social interventions can not only improve the health of members or patients, but even positively impact health care organizations’ bottom lines. Developing and implementing a social needs strategy isn’t rocket science, but it does take some structure and discipline. The roadmap laid out above provides a good approach to developing and implementing social needs strategies for health care organization.