Digesting the Social Determinants of Health One Bite at a Time


The healthcare landscape is rapidly changing. One key topic that is consistently at the forefront of this transition is how communities can advance population-wide health improvement efforts. Population health, however, is not always well defined and can mean different things to different people. This is particularly true for community population health. The goal of this discussion is to break down community population health into digestible pieces by looking at the role social determinants of health play in high-risk patients in the community, identifying these high-risk individuals, and defining innovative models that improve access to care.

The Social Determinants of Health

While the drive for higher quality care and lower overall costs has been ongoing for many years, the impact of social determinants has not been seriously considered until recently. The focus on high-need patients has highlighted the impact of these social factors on care, and what can be done to mitigate their negative effects. As you have worked with high-need patients, it is likely you have encountered some, if not all, of the social determinants we will address.

The Department of Health and Human Services defines social determinants as social, economic, and physical conditions of an individual’s life and the surrounding environment, such as income, house, and nutritional factors, that impact the health outcomes of individuals. Essentially, they are the factors that influence our health outside the walls of the hospital. Common social determinants include housing, social services, geographical location, and education. If patients have better health and support in these areas, they are less likely to require the medical services provided by doctors and other care providers.

Due to the considerable number of social determinants, it will be helpful if we understand the broader classifications used to define them. The four primary social determinants of health are:

Socioeconomic Factors

Poverty can limit access to healthy food, safe neighborhoods, and good schools. Poverty can also lead to homelessness. According to the Corporation for Supportive Housing, “Access to safe, quality, affordable housing—and the supports necessary to maintain that housing—constitute one of the most basic and powerful social determinants of health.”

Social Supports and Public Good

Certain populations need community partners to advocate for their health equity. Some examples include housing departments working with homeless patients, or health care advocates helping single mothers. Fire and police departments are also public safety partners as they can help reduce drugs, crime, and violence which negatively impact neighborhoods.


Patients in rural areas have limited access to medical facilities and providers. The sheer distance to the nearest facility is often a barrier to care.  Technology, such as telehealth, can help bridge this gap, but requires access to broadband technology which is not always available.

Educational Attainment and School Intervention

There is a correlation between quality education and better healthcare outcomes. Patients who have attained higher levels of education have increased capacity to advocate for themselves and engage with providers.

One of the most thorough analyses on the impact of social factors is the 2017 report by the National Academy of Medicine (NAM) entitled, Effective Care for High-Need Patients. It highlights how social determinants are generally more pronounced in this population, but with the adoption of updated treatment plans, social determinants can have the greatest positive impact.

Identifying High-Risk Patients

This high-need patient population is diverse and, consequently, difficult to target. NAM has identified three primary criteria for defining this population: 1) total accrued health care costs, 2) intensity of care utilized for a given period, and 3) functional limitations. These criteria are common across diverse patient populations.

To better understand these common elements, patient classifications are used to categorize these factors in the research. The NAM study found that a classification focused primarily on medical characteristics is likely to neglect other key social determinants that can significantly impact quality and cost of care. An effective classification for high need patients must provide guidance on how to embed social risk factors, behavioral health factors, and functional limitations. To achieve this, patients first need to be assigned to a clinical segment, with an accompanying assessment of behavioral health and social service needs to determine the specific types of services required.

As providers conduct these assessments, you will discover key behavioral health factors most likely to affect care delivery decisions. These will include substance abuse, serious mental illness, cognitive decline, and chronic toxic stress. Key social risk factors include low socioeconomic status, social isolation, community deprivation, and housing insecurity. Classifications are designed to align high-need patients with the care models that target their specific needs and include:

  • Assessments that are multidimensional (medical & social factors)
  • Targeting those most likely to benefit
  • Evidence-based care planning
  • Aligning patient goals and functional needs with appropriate care
  • Training both patients and providers to promote better engagement, education, and coaching
  • Coordinating care and communication between patients and their care team

Research shows the demographics of high-need patients are less educated, more likely to be publicly insured, have fair to poor self-reported health, and are susceptible to lack of coordination within the health care system. Addressing only clinical needs will have little to no impact on improving outcomes or lowering costs. Achieving desired outcomes requires improving an individual’s functional, social, and behavioral needs, primarily through coordination with social and community services that typically fall outside the province of healthcare delivery systems.

Innovative Care Models

According to NAM, delivery features of successful care models include:

  • Multidisciplinary care teams with a single, trained care coordinator as the communication hub and leader
  • Extensive outreach and interaction among patients, care coordinator, and care team, with an emphasis on face-to-face encounters among all parties and collocation of teams
  • Speedy provider responsiveness to patients and 24/7 availability
  • Outreach, including the extension of care to the community and home

The report explores how policy initiatives can accelerate and expand care models for high-need patients through value-based payment models, improving the organization of care, developing a workforce to deliver comprehensive health care, and improving the data infrastructure. Federal and state governments must work with local partners to promote a strategy which incentivizes evidence-based social support services in conjunction with the delivery of medical services. To improve data infrastructure, successful care models must identify barriers that inhibit data flow among clinicians and organizations and work to minimize these barriers while respecting patient privacy and data security.

As we work to improve access to care for high-need patients, our efforts should be driven by the IHI Triple Aim of Healthcare—improving outcomes, improving care quality, and reducing the cost of care. Understanding social determinants can help all of us understand the needs of our patients and make accommodations to alleviate the negative effects of those determinants. At the forefront of these considerations is cost. Increasing out-of-patient costs have proven prohibitive for all patients, especially those with high needs. Recent research shows that 25% of respondents in a Physicians Foundation poll indicated they are discontinuing their care due to cost burden.

Opportunities for action highlighted by NAM’s research include:

  • Integrating and coordinating the delivery of medical, social, and behavioral services to reduce the burdens of patients and caregivers
  • Developing approaches for spreading and scaling successful programs and for training the workforce to successfully implement these models
  • Promoting payment reform efforts that further incentivize the adoption of successful care models and the integration of medical and social services
  • Creating roadmaps and tools to help organizations adopt models of care suitable for their patient populations

With the repeal of the Affordable Care Act still up in the air, we will continue to see a lot of transition in the delivery of healthcare, especially for high-need Medicaid beneficiaries. Communities that establish collaborative care models that address all aspects of an individual’s health, and understand how to identify these individuals, will play a leading role in advancing population-wide health improvements, despite the uncertain future.

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