Social Determinants in a New Era of Healthcare

February 15, 2017 Beth Anctil

As the saying goes, we are products of our environment. Social determinants of health, or conditions in which people live, learn, work and play, can all influence how healthy we are. Everything from the quality of schooling to the cleanliness of water can impact a community’s overall health.

Healthy People 2020, a program for improving the nation’s health, developed a framework to reflect five key areas (determinants) to categorize the social determinants of health:

  • Economic Stability
  • Education
  • Social and Community Context
  • Health and Healthcare
  • Neighborhood and Built Environment

Social structures and environmental conditions in these key areas can result in unequal care delivery, which partly explains why some Americans are healthier than others. And as the movement toward managing targeted patient populations continues to gain momentum, social determinants of health are increasingly seen as critical components of care management in a value-based care environment.

Just how important are social determinants of health? One analysis found that clinical care was responsible for as little as 10 percent of the impact on health outcomes in some states.

How do I improve care for people that are affected by the social determinants of health?

Providers have identified and continue to test a number of programs and initiatives to manage the social determinants of health. These include, but are not limited to:

Care Management

A number of health systems have created care teams of nurses, social workers and community health workers to provide high-touch care to high-cost patients.


Partnering with Community Organizations

Joining forces with local organizations, including faith-based communities, schools, and organizations created to help those in poverty, to create a safety net for patients is another approach to managing social determinants of health. These initiatives expand the network of groups with a stake in patients’ health.

Health Education

Providing appropriate healthcare education to patients and staff is one of the easiest ways to influence health decisions made outside of the hospital. Staff should have an in-depth understanding of health literacy issues and cultural sensitivities.

Asset Mapping

Bringing together community groups that provide similar services and recording detailed information on those services can forge relationships and create important networks for providers and patients.

Is there a financial benefit?

Many hospitals and health systems are stretched thin financially on a number of levels. Initiatives that are not affordable are often simply off the table. How can managing, or not managing, social determinants of health impact the bottom line?

Readmission rates: Implemented effectively, programs that manage social determinants of health will reduce readmission rates for high-utilizers, thus decreasing associated penalties.

Capitated payments: Health systems implementing programs with capitated payments for beneficiaries will create savings by reducing unnecessary hospitalizations.

Uncompensated care: Targeted care management for specific populations can provide patients with the resources they need to use the hospital appropriately; reducing uncompensated care while increasing preventative care.

State and federal grants and initiatives: A number of funding sources are available on the state and federal level for the implementation of programs that address social determinants of health.

A lack of aligned incentives can pose many challenges for stakeholders interested in addressing the social determinants of health. A return on investment may be realized if these services target the appropriate patients. Putting policies in place that positively influence social and economic conditions can improve health for a vast number of people over time. Providers can begin thinking about areas of opportunity when building out their population health strategy in this new era of care delivery.

Need help working on your own population health management plan? Our team of expert consultants, recently recognized as Best in KLAS in value-based care consulting, can help accelerate your transition to effective population health management.

Author information

Beth Anctil

Beth Anctil

Beth Anctil leads the Clinical Transformation Team in Population Health Advisory Services for Premier Inc. With over 35 years of healthcare management experience spanning settings across the continuum of care, she has proven leadership skills and success in fully deploying initiatives to transform models of care. Connect with her on LinkedIn.

The post Social Determinants in a New Era of Healthcare appeared first on Action For Better Healthcare.


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