Social Determinants of Health

Toward Addressing Social Determinants of Health: A Health Care System Strategy

November 17, 2018

Toward Addressing Social Determinants of Health: A Health Care System Strategy

In the US, there is growing recognition that social factors (eg, financial hardship, food insecurity, housing instability) influence individual and population health. This has led to increased efforts to address these social determinants of health (SDH) within the delivery system. Yet, limited information exists about the strategies health care systems employ to identify and address SDH. Kaiser Permanente Northwest (KPNW) is an integrated health care delivery system that has implemented a comprehensive approach toward addressing its patients’ SDH. This article describes the tools and processes used at KPNW for identifying and addressing SDH.

Tools included use of electronic health record-based data elements, International Classification of Diseases, Tenth Revision social diagnostic codes (Z codes), and the development of novel workflows via nonclinical patient navigators to address patients’ SDH through community resource referrals. Between March 31, 2016, and March 25, 2018, KPNW patient navigators screened patients with SDH.

Patient navigators screened 11,273 patients with SDH, identifying and documenting 47,911 SDH in the electronic health record. During the same 2-year period, 18,284 community resource referrals were made for 7494 patients.

The novel electronic health record-based tools developed by KPNW have led to standardized, measurable, and actionable SDH data being used to tailor and target specific resources to meet the identified needs of our patients. By disseminating information about these efforts at KPNW, we aim to help build an evidence basis of different approaches for addressing SDH within the health care system as well as defining opportunities to improve care efficiency for patients with SDH.

The full article can be downloaded below.  


Considerations for Success in Addressing Social Determinants of Health at the Individual Level

October 26, 2018

Social Determinants of Health (SDOH) are the conditions in which people are born, work, live, and age. The healthcare industry increasingly recognizes that improvements in health and health equity will only be possible after addressing SDOH, including socioeconomic status, education, neighborhood and physical environment, social support networks, and access to healthcare. Currently, payers use ZIP code characteristics to determine investments at the neighborhood level. The approach does not consider customized resource allocation at the individual level unless the member/patient has had multiple, high-cost interactions with the healthcare system (i.e., “hotspotting”).

UnitedHealthcare (UHC) is piloting a more targeted approach to addressing SDOH and will be tracking the results of the pilot work closely.

The steps of the pilot are:

  1. Identify “at-risk” members/patients using specific ICD-10 codes, CPT codes, and LOINC codes on claims
  2. Have care managers perform direct outreach to conduct assessments to evaluate specific needs
  3. Generate/update care plans that treats the entire patient, including social, medical, and behavioral services to address member-specific needs
  4. Connect members/patients to other payers, such as Medicare and Medicaid, if appropriate
  5. Enroll members/patients into relevant UHC programs, such as literacy programs or programs around self-care
  6. Arrange follow up
  7. Go back to step 3

These Considerations for Success were discussed as part of eHealth Initiative’s September 2018 Value & Reimbursement Workgroup meeting as presented by Anupam Goel, Chief Health Information Officer, Clinical Services, UnitedHealthcare.

Social Support is Associated with Medication Adherence

June 27, 2018

Social Support is Associated with Medication Adherence

Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined.  Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Thus increasing social support with combined structural and functional components may help support medication adherence.


The full article, entitled "Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study" can be viewed below.  

Creating a Conduit for Better Health: Technology Connects Medical and Social Services

October 27, 2017

Kimber finally left when her husband tried to choke her and said he wished  she was dead.
The marriage started out well, she tells  her women’s shelter counselor, until he started drinking too much. Then the violence began. Today, she’s the mother of two young girls, without a job, a car, a home, personal security, family or social support. 

Fortunately for Kimber, the shelter  she found is part of Boulder County Department of Housing and Human Services’ integrated system of social services providers. She will only have to tell her story once, and the shelter worker will assess all her health needs—social, emotional, physical and financial. She’ll help Kimber sign up for Medicaid coverage for the family, apply for food and housing assistance, job training, mental health counseling, transportation and shelter. In Boulder County, they call this a no-wrongdoor approach to serving clients.

What’s more, Kimber’s assessment data will be entered, real-time, into an integrated data warehouse. Dozens of organizations— serving social, mental and physical health needs—will be able to find her in this system. They can add notes to the record as services are provided, or as case managers create a care plan—with Kimber—to help her achieve her goals. And Kimber can also access her information through a client portal—so she can track her own progress.

Connecting health care providers through an electronic records platform is not a new concept; about 99 percent of U.S. hospitals had partially or completely implemented electronic health records in 2016, with many allowing at least limited access  by contracted physician offices and  group practices.1 Less pervasive, but  not uncommon, are health information exchanges (HIEs) that allow health care providers and patients to access and securely share a patient’s medical information electronically. 

An S-HIE brings together the many community-based organizations that meet client needs for the social determinants of health—such as housing, food, safety, transportation and employment—and links them with organizations that provide mental, behavioral and physical health services as well. It’s a bridge connecting health care delivery and the real-life circumstances in which people live, work and play—the social determinants of health that contribute to our nation’s high health costs.

Adoption and Use of Social-Behavioral Determinants of Health

October 18, 2017

Webinar recording and presentation slides from 10/18/17 webinar presentation on the Adoption and Use of Social-Behavioral Determinants of Health. 

Social determinants, the circumstances in which people live and work, have a strong effect on health and are linked with the development and management of chronic conditions. More than 35 social-behavioral determinants of health have been recommended by four federal institutions and the National Academies of Sciences, Engineering and Medicine. 

During this webinar Speakers will provide:
- Practical tips and advice to leverage Social-Behavioral Determinants of Health to maximize healthcare outcomes
- Guidelines for the prioritization, selection, implementation and application of social-behavioral determinants of health
- A standardized evidence-based approach to normalize the collection of Social-Behavioral Determinants of Health across settings

- Ruth E. Wetta, RN, PhD, MPH, MSN, DataInsights, Lead Clinical Researcher, Cerner, Adjunct Associate Professor, University of Kansas School of Nursing
- Marina Daldalian, MPH, Senior Clinical Researcher, Cerner
- Sue Gullickson, Project Manager, Performance Excellence, Agnesian HealthCare

Measures of Patient Activation and Social Support in a Peer-Led Support Network for Women with Cardiovascular Disease

October 17, 2017

Study from Witt, Benson, Campbell, Silah, and Berra (2016) describing the structure of peer-led support groups offered by WomenHeart: The National Coalition for Women Living with Heart Disease and assesses participants' quality of life and social, emotional, and physical health.

Effects of Social Needs Screening and In-Person Service Navigation on Child Health

September 06, 2016

IMPORTANCE Social determinants of health shape both children’s immediate health and their lifetime risk for disease. Increasingly, pediatric health care organizations are intervening to address family social adversity. However, little evidence is available on the effectiveness of related interventions. CONCLUSIONS AND RELEVANCE To our knowledge, this investigation is the first randomized clinical trial to evaluate health outcomes of a pediatric social needs navigation program. Compared with an active control at 4 months after enrollment, the intervention significantly decreased families’ reports of social needs and significantly improved children’s overall health status as reported by caregivers. These findings support the feasibility and potential effect of addressing social needs in pediatric health care settings. Gottlieb et al., 2016.

Screening for Basic Social Needs at Medical Home for Low-Income Children

January 01, 2009

The goals of this cross-sectional study were to (a) describe the prevalence of 5 basic social needs in a cohort of parents attending an urban teaching hospital–based pediatric clinic, (b) assess parental attitudes toward seeking assistance from their child’s provider, and (c) examine resident providers’ attitudes and behaviors toward addressing these needs. Parents (n = 100) reported a median of 2 basic needs at the pediatric visit. The most common was employment (52%), followed by education (34%), child care (19%), food (16%), and housing (10%). Most parents (67%) had positive attitudes toward requesting assistance from their child’s pediatrician. The majority of resident providers (91%) believed in the importance of addressing social needs; however, few reported routinely screening for these needs (range, 11% to 18%). There is great potential for assisting low-income parents within the medical home. Further practice-based interventions are needed to enhance providers’ self-efficacy to screen and address low-income families’ needs at pediatric visits. Garg et al., 2009