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SDOH: An emerging population health priority

In recent years, both public health and not-for-profit organizations have increasingly been focused on addressing social determinants of health (SDOH) and their impact not only on each individual’s overall wellness but also on the ability of people to access healthcare services.a It has been a focus of CMS’s Healthy People 2030 effort, which has made a broader audience aware of SDOH issues.

Up until now there has been a lack of coordination of investment in these “upstream” issues, and lack of a standardized approach for addressing SDOH in community and clinical settings.

With a new administration comes a new focus

But we may be at a tipping point in the market given the new Biden administration’s support for strengthening the Affordable Care Act. With the growing interest of Medicare Advantage (MA) and state Medicaid programs in paying for outcomes, there is an increased focus on strategies that address the social needs that contribute to improved health outcomes and help control unnecessary healthcare utilization.

For example, Michigan now requires Medicaid plans in the state to submit a multi-year SDOH plan. CVS Aetna’s 2021 MA plans will focus on total health and SDOH benefits. Anthem likewise is expanding MA benefits that target SDOH, and is increasing by 20% the number of counties where it offers MA plans.

Much work yet to be done

Addressing SDOH also is an enormous undertaking. The overall concept of SDOH comprises at least a dozen factors, including:

  • Lack of affordable housing and utilities

  • Food insecurity

  • Gender inequity

  • Racial discrimination

  • Lack of or limited health insurance

  • Adverse workplace conditions

  • Substance abuse and mental health

  • Threats to personal safety

SDOH options that have been found to reduce utilization of both inpatient acute care services and emergency departments (EDs) include:

  • Providing supportive housing for mentally ill people who would otherwise be homeless

  • Helping adults with chronic conditions and low incomes access food stamps or supplemental nutrition assistance programs (SNAP), or providing them with home meal delivery

  • At the state level, classifying community-based services as covered Medicaid benefits so the state can receive federal matching funds that cover the cost of signing people up for social programs

  • Using value-based payments for SDOH interventions, thereby giving providers latitude to offer beneficiaries cash or vouchers for one-time out-of-pocket emergencies, such as transportation, utility costs or more consistent access to food

Progress has been slow to date, but there is reason for optimism. In a recent report, the Robert Wood Johnson Foundation concluded, “While none of the tools at states’ disposal can single-handedly resolve underlying gaps in the societal safety net, they provide important opportunities to offer social support that will have direct impact.”

Organizations also are stepping in help drive progress. The newly formed National Alliance to Impact the Social Determinants of Health (NASDOH) is a national advocacy organization of healthcare industry stakeholders — both payers and providers — that aims to focus national attention on SDOH to improve health and well-being while reducing long–term spending on healthcare. NASDOH has noted that current silos of federal spending programs in health and social services limit program integration at federal, state, and local levels and allow few opportunities for collaboration and innovation.

To help address this challenge, the alliance has issued SDOH recommendations to the Biden transition team (see the sidebar). These recommendations could see some traction, based on the incoming administration’s voiced leanings around healthcare policy, including support for expanding and improving the Affordable Care Act.

How to impact SDOH 8 recommendations from the National Alliance to Impact Social Determinants of Health (NASDOH) to President Biden’s transition team:

  1. Make SDOH a new national priority.

  2. Use program funding to sharpen SDOH focus across the executive branch.

  3. Enhance prioritization and coordination of SDOH within the U.S. Department of Health & Human Services.

  4. Improve regulatory assessment of SDOH policy changes.

  5. Use a healthcare financing mechanism to support SDOH activity.

  6. Revitalize public health, a key SDOH partner.

  7. Modernize data infrastructure to support SDOH data-sharing.

  8. Support research and development to address SDOH.

SDOH initiatives

Many current initiatives illustrate the various ways SDOH efforts have been gaining traction recently. The following are just a few prominent examples.

The Leadership Initiatives Support Corporation (LISC). LISC is a national community development organization that is partnering with healthcare systems such as Sentara and its Optima Health Plan to build affordable homes and apartment projects in low-income urban areas. LISC is in the middle of a 10-year $10 billion national effort to connect community investments to healthcare gains. In addition to housing and jobs creating commercial real estate, LISC has invested in over 100 healthy food projects, grocery stores and farmers markets, and over 90 health projects including healthcare centers. Under the terms of the partnership, Sentara will contribute $50 million to finance the partnership goals, and LISC has committed to matching the investment from public and private sources with the aim of dealing with social issues that cannot be tackled inside the walls of a healthcare facility.

Colorado Hospital Association (CHA) partnership with Carrot Health. The CHA recently completed a study with Minneapolis-based Carrot Health, Inc., reviewing data from all CHA members to map the correlation of SDOH with ED utilization and hospital readmissions in the state. The analysis identified key underlying factors driving super-users of EDs, including food insecurity, housing instability and discord at home.d The study developed a methodology to allow CHA members to identify:

  • Significantly high-risk populations

  • Optimal intervention opportunities

  • Efforts most likely to produce the greatest ROI

The Center for Medicare and Medicaid Innovation (CMMI) Accountable Health Communities Model. Launched in 2016-17, this initiative is a five-year, $157 million SDOH effort being conducted in 29 urban and rural communities across the nation to assess whether systematically screening for and addressing SDOH can reduce healthcare costs and utilization among Medicare and Medicaid beneficiaries. A screening tool has been developed to identify patient needs in five different areas, which can be addressed through community services (i.e., housing instability, food scarcity, transportation difficulties, utility needs and personal safety). The tool is streamlined enough to be incorporated into clinical workflows with results that can be used in a patient’s treatment plan as well as to make referrals to community services.

The Oregon Accountable Health Communities (AHC) study. Funded through Oregon Health & Science University, the AHC study is part of a CMMI demonstration that provides screening for Medicare and Medicaid beneficiaries in 50 communities across the state, linking them with social services to meet appropriate SDOH problems.

Personalized assistance in navigating Oregon’s 211 info social services system is provided for high-risk clients. By coordinating closely with Oregon Coordinated Care Medicaid program, which operates under a CMS 1115 Waiver, AHC can secure cash payments for such items as emergency transportation, utilities or legal services not covered in the larger CMS study. In an interview, the AHC project director, Anne King, reported that SDOH problems increased 50% due to the pandemic, but that the program has been able to “seamlessly” address these problems by switching from in-person to mainly virtual client contacts.

The Utah Alliance for the Determinants of Health. Another noteworthy SDOH effort is this three-year demonstration program in Utah. The Utah Alliance was launched in 2018 by Intermountain Healthcare and several community partners, which have invested $12 million to address SDOH needs of Medicaid recipients in two counties in northern and southern Utah. Key program elements are:

  • Developing countywide care teams to bring community and clinical resources together

  • Connecting individuals electronically with clinical and social service providers

  • Partnering with Unite Us, a technology company, to build a data system linking health and social service providers

Assuming the results from 2020 are positive, Intermountain plans to roll out Alliance program elements, including its data system, across the communities it serves.

ProMedica partnership with LISC Toledo. ProMedica, a regional health system based in Toledo, Ohio, serving 28 counties in southeast Michigan and Ohio, has worked for more than a decade to address the social, economic and community factors impacting health in the communities it serves. ProMedica’s focus on SDOH has sparked a comprehensive effort to stabilize the area’s aging affordable housing stock, revitalize a predominantly low-income neighborhood and strengthen Toledo’s economic base by investing in downtown improvements. In 2017, ProMedica entered a10-year partnership with LISC Toledo to provide $20 million in grants for community programs and services and an additional $25 million to develop affordable housing.

Data-driven approach to address SDOH

One underlying principle has emerged from current SDOH initiatives: Success depends on developing clear and measurable objectives. This effort starts with understanding a community’s demography, geography and population health data to chart a path for improvement.

Screening for social needs is still not standard clinical practice in many health systems. In many communities, the absence of established pathways and infrastructure, coupled with perceptions of lack of time to make community referrals, are barriers sufficient to prevent clinicians and their staffs from addressing health-related social needs at all, according to a 2017 report of the National Academy of Medicine.e The report discusses the Accountable Health Communities Model that CMS is testing to ascertain whether systematically addressing the health-related needs of Medicare and Medicaid beneficiaries impacts their total healthcare costs and improves health. Standardized screening is deemed to be an essential tool for this purpose.

For example, Pro-Medica uses an “Anchor Dashboard” with 10 metrics to understand the implications for health of its non-clinical investments.f The Anchor Dashboard includes:

  • Economic and community development

  • Education and job creation

  • Thriving business and equitable employment

  • Personal finances

  • Social determinant screening

  • Hunger

  • Housing

  • Infant mortality

  • Arts/cultural development

  • SDOH research

An important lesson learned from the many SDOH experiments is that community organizations can effectively work across the siloed borders that have traditionally divided health services and social services. What is required is that shared data and tools be employed systematically to work toward common goals, including reduced avoidable healthcare utilization.

Advocating for the coordination and integration of SDOH into the healthcare delivery system, especially for Medicare and Medicaid populations, will be a critical step in advancing this effort, and it is a step likely to gain support under the incoming Biden Administration.


a Garrett, D., Hwang, A., Pierce-Wrobel, C., “Social determinants of health: a public health concept in conflict,” Health Affairs Blog, May 30, 2018).

b Billioux, A., et al, “Standardized screening for health-related social needs in clinical settings,” National Academy of Medicine Perspectives, May 30, 2017.

c Manatt, Phelps & Phillips, LLP, “Medicaid’s role in addressing social determinants of health,” Robert Wood Johnson Foundation, Feb. 1, 2019.

e Billioux, A., et al., “Standardized screening for health-related social needs in clinical settings: The accountable health communities screening tool,” Discussion paper, National Academy of Medicine, Perspectives: Expert Voices in Health & Health Care, May 30, 2017.

f Oostra, R., Zuckerman, D., and Parker, K., Embracing an Anchor mission: ProMedica’s all-in strategy, ProMedica and the Democracy Collaborative, May 2018.

An emerging population health priority
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Dudley E. Morris

Senior Advisor

San Francisco and Los Angeles 312-286-4865


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