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Social Determinants of Health Programs Improve Health Outcomes

Social Determinants of Health Programs Improve Health Outcomes


The social determinants of health (SDOH), the conditions in which we are born, live, learn, work, play, worship, and age, have a significant impact on health outcomes. Research shows that a whopping 80-90% of health outcomes are dependent on SDOH factors, while medical care only accounts for about 10-20%. New clinical-community partnerships designed to address SDOH, however, are showing promise in improving patient outcomes.

Adverse SDOH make patients sicker

The burden of disease is greater among those living with adverse SDOH. A study of primary care patients with a chronic medical and behavioral condition or 2+ chronic medical conditions found that almost a third of patients had at least one SDOH insecurity. Among those experiencing an SDOH insecurity, functional capacity was greatly reduced. This worsens quality of life and impedes patients’ ability to effectively manage their conditions.

Beyond chronic disease management, SDOH also increases mortality rates. Results from a national survey of self-reported SDOH factors showed that people facing unfavorable SDOH were at higher risk for premature death. And the prevalence of unfavorable SDOH was much higher in Black and Hispanic populations compared to their white counterparts.

A 2023 article in Medical Care found minimal medical record documentation of SDOH factors among individuals who died by suicide. And compared to randomly selected controls, documented adverse SDOH factors were associated with higher suicide odds. Addressing social needs in clinical settings can be the difference between life and death for patients.

Primary care providers are on the front line of addressing SDOH

For most, primary care providers (PCPs) are the gateway to the health system. They serve as the partner, the educator, the coordinator and the motivator for patients as they navigate their conditions. Patient-centered approaches and shared decision-making tools can enhance the patient-provider relationship and empower patients to take an active role in managing their health.

PCPs also have the unique opportunity to capture which types of SDOH may be affecting their patients. A recent review suggests that SDOH screening improves patient health outcomes. By asking about insecurities that patients are facing, PCPs can better understand their whole health, connect them with social services and equip them with more tailored treatment plans.

Documentation alone won’t provide access to critical resources for patients facing adverse SDOH. But clinical settings don’t always have the financial or workforce bandwidth to implement SDOH programs. Nor are they trained to be the social worker, lawyer, and housing specialist. This is where partnerships with community-based organizations (CBOs) come in.

Closed-loop referral programs create patient-centered approaches to care

CBOs often specialize in addressing one or more SDOH insecurities. They can be helpful partners to PCPs by providing access to resources that clinical settings don’t typically have. Communication, ideally in the form of a closed-loop referral program, between clinical settings and CBOs is a key to success for these programs.

In a closed-loop referral program, clinicians screen for and document SDOH insecurities their patients are facing. Then a referral is placed to the relevant CBO, often through an electronic medical record (EMR)-integrated software or other third-party software. The CBO receives the referral, connects with the patient to provide them resources, then communicates back with the clinician on the outcome of the encounter.

This type of program allows clinicians and CBOs to focus on their respective specialized skillsets while keeping the patient’s needs at the center of the process. Implementation costs can be high though, especially when accounting for EMR integration and provider training. CBOs also sometimes lack capacity and resources to meet the needs of every patient.

Changing the healthcare cost structure

Adding payers into the closed-loop referral program can help reduce some of the resource burden for CBOs. By including CBOs in the provider network and reimbursing them for their services, their capacity for additional patients can increase.

From a system perspective, healthcare providers and payers should have a vested interest in reimbursing CBOs for their services. Investments upstream can prevent higher downstream costs. Many chronic diseases, for example, have SDOH roots and are preventable. Addressing SDOH insecurities for such patients, especially proactively, can reduce long-term healthcare costs.

Some communities are already doing this effectively. In North Carolina, the NCCare306 pilot program allows Medicaid to reimburse CBOs for certain services that address SDOH insecurities. Since March 2022, the program has delivered over 208,000 services to Medicaid members with a 93% payer approval rate.

The road to addressing SDOH isn’t necessarily easy. But the U.S. has the highest healthcare costs and the worst health outcomes compared to every other developed nation in the world. Status quo is not acceptable. It’s time to pave the way for innovative partnerships among clinicians, payers, and CBOs.

Michelle Sabia

Michelle Sabia, MPH, CPH has a passion for health equity and has dedicated her career to supporting underserved populations through education, direct service programming, and advocacy. She is certified in public health and received her master’s in public health from George Washington University. She has over a decade of experience in healthcare nonprofits and healthcare delivery settings managing federal payment programs and community health initiatives, and implementing programs that address social determinants of health. In her current role at HealthyWomen, she serves as the program manager of the military women’s health program developing education for military healthcare providers and active-duty servicewomen.

Michelle Sabia
Michelle Sabia



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Suicide has reached epidemic proportions in the US − yet medical students still don’t receive adequate training to treat suicidal patients

Suicide has reached epidemic proportions in the US − yet medical students still don’t receive adequate training to treat suicidal patients