by Jessica Baker, Associate, Healthbox

In addressing the social determinants of health (SDOH), we frequently talk about the lack of a single, agreed-upon definition for the term, a unified or comprehensive list of determinants, or a standard guidebook for what a health system should do to help address these patient needs. To be fair, fulfilling all three of these requirements is a tall order in and of itself, with no true owner responsible for consolidating the existing breadth of information, making tackling social determinants all the more challenging, but not impossible.

Health system leadership must ask themselves a series of questions when charged with addressing patient health outside of the hospital setting:

  1. How are we defining the social determinants of health?
  2. Which social determinants are affecting our patients the most?
  3. How do we collect data around these social determinants and what do we do with it once we get it?
  4. What is a strategic, sustainable approach for helping our patients thrive that:
    • Sets patients up for long-term success rather than short-term relief;
    • Accurately assesses a patient or community’s level of risk in a particular determinant area;
    • Does not reinvent the work of community organizations, but enhances and builds on work that has already been done;
    • Helps to connect patients with existing community organizations and ensures they are able to follow through; and
    • Tracks the success of the initiative over time in a quantitative, actionable way?

These questions can be difficult to answer for organizations that have traditionally been focused solely on the medical aspects of patient care. Asking them to start to look at the patient journey beyond the four walls of the health system, at work, at school, or at home, is akin to asking a plumber to determine why your pipes keep getting clogged: while they may be capable of digging in to figure out that bathing and brushing your sheepdog in the bathtub without a hair stopper isn’t the best idea, it’s out of the scope of the job they were hired to do. More importantly, they may not be equipped with adequate resources to make a fully informed judgment call, particularly considering any outside factors that may be contributing to generally poor drainage in your neighborhood. In the same way, providers of care, insurers, and other large healthcare organizations should not be expected to have all the answers.

However, as research shows us, tangible acute ailments or chronic health conditions are largely a result of a patient’s ability to interact with the health system on a regular basis as well as their access to resources – such as food, medication, transportation, parks/fresh air, housing, education, childcare, a stable source of income, among many others – that allow them to realize their full health potential. When even one of these items is thrown off balance, the others follow suit, including the patient’s physical health. More often than not, particularly in vulnerable populations, you are not faced with just one determinant, but several that are working against your success.

In order to achieve positive health outcomes, healthcare organizations now have to be prepared to not only diagnose their patient’s physical ailment, but also set them up for success in adhering to their treatment plan: they are not only solving the problem, but looking for its root cause. In the changing health ecosystem, we all have to be prepared to take on new roles, alleviating the burden that has been focused on government, community, and philanthropic organizations to-date and spreading the work across anyone with the ability to contribute.

Strategic Prescribing

While all of this talk and planning sounds good, as a physician, how do you decide whether a treatment plan will be feasible for your patient to follow based on unknown variables? As a health system, how do you support your staff and your patients, knowing that improving outcomes and reducing readmissions consists of more than just a visit and a prescription?

The key word in effectively addressing social determinants of health is strategy. As a society, we are already well aware of the research surrounding social determinants of health. In a previous blog post, we examined determinants as a trending topic and looked at several of dozens of initiatives appearing on a daily basis working to address a portion of the problem. As these efforts continue, it is crucial to document the work of each new entrant into the social determinants field, build upon it, and learn in order to establish a strategy for sustainable growth, scale, and replicability across diverse populations.

A successful social determinants strategy is rooted in data. EMRs such as Epic are starting to introduce social determinants input fields that help physicians identify high-risk patients and appropriately triage them while they’re in the clinic. Data analytics companies such as Waystar are helping health systems to collect and analyze raw patient data, turning it into risk scores that show areas of highest need; as free text, this data can be filtered into an EMR for easy access during a patient visit.

You have the data, now what?

Every healthcare organization serves a number of unique patient populations, each facing their own unique barriers to accessing care. Using social determinants data, a health system can start to understand where pockets of need exist and begin to evaluate their ability to address those needs.

However, the data is not enough. Traditionally underserved communities are continuously faced with attempts to “fix” them, but many initiatives come from outsiders, people who aren’t living these social determinants. In order to create meaningful change, health systems need to effectively empower community workers, companies, and residents, leverage their existing knowledge base, and partner together to create a synergistic solution.

Baylor, Scott, & White (BSW) serves as an example of this. In 2018, the health system launched a wellness facility in a city recreation center. Meeting these patients at their needs, in their community, reduced ED visits by 21.4% and inpatient care visits by 36.7%. Cost for these services dropped an average of 34.5% and 54.4% respectively. Their vision? To be the most trusted name in giving and receiving safe, quality, compassionate healthcare.

Community trust is a giant piece of the puzzle. Englewood, a neighborhood on the southwest side of Chicago has long struggled with poverty and crime. The life expectancy of its residents is about 70 years. In 2013, Whole Foods decided to open up a location in Englewood. The neighborhood was skeptical: this was not the upscale grocery store’s primary demographic. Working with neighborhood representatives, Whole Foods agreed to:

  • Hire residents, improving job availability and security;
  • Price food items appropriately for the location’s financial demographic; and
  • Partner with local businesses to sell their goods.

While one grocery store has not transformed the neighborhood, it has given new opportunities and options for its residents, adding over 100 jobs to the community. The Whole Foods additionally partners with Operation HOPE, a nonprofit working to disrupt poverty in low- and moderate-income families across the nation by equipping them with the financial tools and education to achieve financial independence and secure a better future.

This example hits at several critical points for health systems to consider in developing a social determinants strategy:

  • Work within your communities rather than bringing in someone from the outside to speak for a specific population;
  • Market your resources properly and educate the community about your plans – no one would step into a Whole Foods if they think they can’t afford it. Similarly, if patients are unaware of the existence, cost, and purpose of a health resource, they won’t use it.
  • Don’t reinvent the wheel: there are plenty of existing resources that do not need to be developed by health systems, but rather invested in to aid in their continued success.

In order to achieve a truly successful, sustainable, and scalable model of addressing the social determinants of health for their patients, health systems must engage in their communities and ask for feedback and support before rolling out an initiative that may not be appropriate, affordable, or empowering for those whom it will be affecting the most.


Healthbox Report: The Healthbox Root Causes of Health Report offers examples of creative and replicable ways organizations have attempted to move the lever in changing the current healthcare landscape.

Article: Social Determinants of Health: Maximizing Momentum

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Addressing Social Determinants of Health: Provider Organization Best Practices


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