Primary Care Doctors and Social Service Providers: Collaboration at its Finest


The rising costs of healthcare are no less concerning today than five or even ten years ago. In 2017, the United States spent $3.2 trillion on healthcare, more than any other nation. At the current rate, it is estimated that by 2024, nearly 20% of the entire United States economy will be spent on healthcare. A massive portion of that spending can be attributed to only about 5% of people in the United States.

According to Dr. Wyatt West (Primary Care Physician at Tanner Clinic) “Disproportionately represented in that 5% are those suffering from chronic health conditions, strongly correlated to low measures on the social determinants of health—the social aspects of health that cannot be treated within the four walls of a primary care practice or hospital, such as income, housing and food insecurity, language barriers, and obesity with all of its comorbid conditions.” Dr. West started Mountain Valley Weight Loss, located at Tanner Clinic in Utah, in order to work with patients on obtaining a healthy metabolic number in order to reduce comorbid conditions.

The healthcare industry has been working to address these social determinants to help lower costs and make lasting improvements in the health of these individuals instead of simply treating their symptoms. But many primary care doctors may well be wondering whether the social determinants of health are even something they can or even should be addressing.

In a Leavitt Partners study looking at the clinicians’ perspectives on access to reliable transport, for example, 66% of respondents agreed that this determinant had significant health outcomes, but only 31% agreed that the responsibility fell on either the provider or the insurer. Among that 31%, most felt that they lacked the resources to provide a solution, confirming an earlier study by the Robert Wood Johnson Foundation in which physicians agreed that addressing the social determinants of health was of great importance but simultaneously were not confident in their availability to do so.

Finding a Way Forward

The Leavitt Partners study concluded that physicians need to figure out strategies to engage the social determinants of health without placing unrealistic burdens on physicians.

In December of 2016, the Advisory Committee on Training in Primary Care Medicine and Dentistry recommended the adoption of a nationwide program to educate healthcare professionals and train them on how they can accomplish this. The report highlighted several strategies, emphasizing partnerships between primary care providers and social services programs and organizations, thereby allowing a whole person, patient-oriented care paradigm to take center stage. Some of these were:

1.     Health Advocacy and Policy

Medical professionals’ voices ought to carry the greatest weight in shaping national, state, and local policies on healthcare to get at the root of patients’ health problems. The report notes that many professionals either feel they haven’t got the time or sufficient security in their jobs to engage in advocacy, or they may not even know where to begin.

The American Medical Association hosts an advocacy conference every year, focused on providing advocacy training to any who hope to learn new strategies and methods. Some of the ways that healthcare professionals have been effective advocates include volunteering for a statewide health board to push for healthcare reform on behalf of those without insurance, hiring a social worker in the practice to increase patient accessibility, or even simply applying for a grant to increase safety measures in apartment buildings to help prevent injury.

2.     Data Sharing

Getting healthcare professionals connected with social services, behavioral services, and other non-medical organizations is the key challenge in this effort, and one necessary element is establishing a way to share data between the various organizations. While this effort should be spearheaded by the primary care provider, the burden of care coordination cannot be left up solely to the physician as their time is already stretched in patient care activities. Furthermore, many primary care providers and Electronic Health Record (EHR) vendors don’t have an apparatus to capture social determinants data, and so it is crucial to establish a system wherein organizations that do record this information can be shared with primary care providers—crucial enough that some are advocating for the inclusion of more SDH data capture in EHRs.

In one successful implementation in Washington called out in the report, an integrated social service client database was established. This database gathered information from a wide variety of sources, including state agencies, Medicaid, criminal justice, and family services. Using a case management system, Washington used this data to help healthcare providers identify patients at the greatest risk—those who use emergency services at the highest rate—and to help develop an intervention plan for these individuals. While doctors are not expected to meet the social needs of these individuals, this database and the connections it fosters enables doctors to connect patients to services that could meet their needs.

3.     Alternative Payment Models

As the country shifts from fee-for-service systems to focus on quality over quantity of care, there are several options that incorporate the social determinants of health in their plan.

One option is the Patient-Centered Medical Home (PCMH) model, wherein a team of healthcare professionals collaborate to oversee patient care. According to this model, the providers must first address the social needs of the patient before payment, with the incentive that the payment will be greater than in a fee-for-service system. In successful instances, similar to the Washington database referenced earlier, a care coordination platform is implemented to help connect social services to primary care providers; the PCMH can see a list of services and through the care coordination platform, they can refer patients to organization or service needed. This platform also enables providers to track their referrals and follow up on outcomes.

The financial feasibility for such models is linked to the savings associated with coordinating care and preventing expensive procedures and services being necessary in the first place. An excellent case cited by the report is the Blue Cross Blue Shield of Michigan, which paid the PCMH team’s enhanced fees with a hefty reimbursement made possible by savings cited at $310 million from 2009 to 2012.


While this is certainly not an exhaustive look at how medical professionals can address the social determinants of health, these are some great places to start. In many of these examples, one of the keys to success was technology that enabled healthcare providers to connect with social services and charitable organizations and refer patients whose social needs require attention. In the end, a successful effort to address the social determinants of health will not only reduce healthcare costs; it will yield significant positive outcomes in patients’ overall quality of life and improve the population’s overall health.

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