by Jessica Baker, Associate, Innovation Consulting

The social determinants of health (SDOH), or the root causes of health—like the neighborhood where you grew up—play a significant role in defining future health outcomes. Research continues to confirm the existence of health disparities based on these determinants. Despite this, root causes of health are seldom addressed in the traditional care delivery setting in the U.S. Part of this has to do with the fact that many U.S. providers lack the appropriate technology and resources that can empower their patients with information that will help them play a more active role in maintaining their personal health.

Meanwhile, the average life expectancy in the U.S. has been decreasing for the last few years, the CDC reports. More alarming is that many of the leading causes of death are preventable, and better understanding and acknowledgement of the root causes of health can help drive prevention.

To improve the health of the nation, focus must increase on treating the whole person—and that means providing patients with the resources they need to take better care of their health.

So how do we make this happen? Our best bet is through spurring collaboration among all relevant stakeholder groups—including providers, community organizations and payers.


Addressing Social Determinants: Provider Pain Points

For most people, an appointment that lasts 20 minutes or less isn’t enough time to treat the whole person, root causes of health and all. That’s why the role of social workers in healthcare is integral; patients benefit from speaking with someone in a health system who can help them find resources to maintain their health. These resources could be a map of community homeless shelters and donation centers, or contact information for free or low-cost clinics, etc.  But despite the social worker’s pivotal role in elevating community health, a 2017 report from the U.S. Bureau of Labor indicates that even in the state with the highest employment level for healthcare social workers (California), only one is employed per every 1,000 jobs.

While it’s not up to a doctor to solve all root causes of health, it’s extremely helpful to understand why a patient might not be following their treatment plan. But without the proper resources and SDOH information to empower both themselves and their patients, it may feel close to impossible to drive change for patient populations with the poorest health outcomes. The fact that hospital reimbursements are based on outcomes—whether or not doctors and/or patients have control over external influencing factors—only adds to the challenge.

Related: Root Causes of Health [A Healthbox Report]

To regain autonomy in care delivery, many doctors are deciding to open their own practices. By doing so, they can be more selective in which populations they treat in order to ensure a greater likelihood of improved outcomes. But if providers are incentivized to only see patients of a certain socioeconomic status to prevent their bottom line from being impacted, health disparities can increase.


Working with Payers for Improvement

As many health systems are somewhere between the transition from fee-for-service to value-based care, developing a strong partnership with payers is crucial. Payers are incentivized to keep their own costs low; so they want to improve patient outcomes, keep emergency department admissions down, address specialty care and chronic illness management, etc. By partnering with health systems, payers can create mutually beneficial plans that fit a health system’s population and unique needs.

North Carolina is addressing this by launching statewide programs that convene health systems, payors, and government officials to collaborate for improved outcomes. Led by Blue Cross NC, five major health systems—Duke University Medical Center, University of North Carolina Health Care, Wake Forest Baptist Health, WakeMed Health and Hospitals, and Cone Health—and their respective ACOs joined forces earlier this year through a commercial program called Blue Premier, with joint accountability for improved outcomes shared by all parties. Implementing programs like this helps build trust between payers and health systems, which is critical to achieving shared goals for better health outcomes.


Collaborating for Healthier Communities

When you live or grow up in an underserved community, it’s clearer than ever that zip codes define health outcomes. Many health systems are taking action to address the root causes of health in a variety of innovative ways—like establishing a food pharmacy within a health system, where patients can be prescribed food to improve their overall nutrition. Additionally, mentoring and violence prevention programs for at-risk youth can help address SDOH outside a provider’s walls. But unfortunately, not all health systems have the means to provide these services to their patients.

Outside a health system’s walls, patients need easy access to the resources they require in order to adhere to treatment plans. That’s why community health organizations are becoming intentional about how they reach individuals with the resources they need to improve their health—like locating resources and clinics where community members are consistently active, such as a grocery store.

Initiatives like My Block My Hood My City are making a difference through direct interventions within communities to support underprivileged youth. The program helps youth see beyond their communities by introducing them to opportunities that exist outside their neighborhood including exploring new cultures, cuisines and communities meant to spark inspiration and adventure. These experiences can help drive individual contributions to a brighter future, encouraging youth to help their communities further evolve.

Organizations focused on improving community health should not only meet patients where they are; they should also develop relationships in order to bridge the gap between health systems and the populations they serve. Establishing that trust is key; oftentimes people are uncomfortable accepting the help they need to improve their physical, mental, and/or financial health from a large institution that may not know what their everyday lives look like. An individual is more likely to trust and listen to someone who lives within their community, and in most cases, a person’s community is the central setting where their health story takes place.

Like most important endeavors, the promise for change lies within our potential to collaborate with all relevant stakeholders. If we can work together to address SDOH and how they impact the lives of individuals, we’ll be well on our way to activating positive change at the community level and beyond.



Addressing Social Determinants of Health: Provider Organization Best Practices

Social Determinants of Health: Maximizing Momentum

Social Determinants of Health: Defining Root Causes of Health


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