SDoH is a hot topic because of a growing body of evidence that shows just how powerful social factors are in determining health outcomes. Research indicates that only 20% of health is driven by health care, another 20% by genetics, and the majority, 60%, by social, environmental, and behavioral factors (healthaffairs.org/doi/full/10....). Because of this, health care is increasingly looking to address the social needs and upstream social determinants of health.

Increasingly, the social determinants of population health have become the over ridding problem for our nation's HEALTH. Here's the list: maternal mortality, child neglect/abuse, childhood obesity, adolescent suicide/homicide, substance abuse, mass shootings, homelessness, mid-life depression/disability, and decreasing longevity at birth(now 4 years in a row).

Given the generational attributes of social determinants, it would be very difficult for our nation's healthcare industry to assume the responsibility for resolving these problems. This is not to say that social determinants should not be considered within a comprehensive healthcare plan for the Basic and Complex Healthcare Needs of every person. However, a national plan to ameliorate and mitigate each community's unique cultural and ecologic social deficiencies would currently be impossible to achieve.

Any national plan to reduce the social determinants of HEALTH must be supported and verifiable by a set of concepts representing a "unified epistemology." I list the following concepts as a proposal. Alphabetically, they are as follows: CARING RELATIONSHIP, CLUSTER, COLLECTIVE ACTION, COMMUNITY, DISRUPTIVE PROCESSES, FAMILY, HEALTH,
PERSON, SOCIAL CAPITAL, SOCIAL COHESION, SOCIAL DILEMMA, SOCIAL MOBILITY, and SURVIVAL COMMONS (augmented safety net).

If you accept severe cognitive dissonance as the basis for the PARADIGM PARALYSIS underlying the reform of our nation's healthcare reform, then a serious national reconciliation regarding the thirteen concepts is in order. As a reminder, our nation's maternal mortality ratio has worsened steadily for more than thirty years. Conceivably, 700 women die ANNUALLY in association with a pregnancy solely because they were living in the wrong nation at the time of conception.

There are many examples of successful models that address health-related social needs of patients. One example is the Commonwealth Care Alliance, a Medicare Advantage plan and care delivery network that uses flexible benefits to offer services traditionally not covered by Medicare and Medicaid to dual-eligibles. Interprofessional care teams assess unmet social needs of patients and providers are given authority to deploy needed resources to address them. The program has successfully reduced hospital admissions and emergency department visits for patients (commonwealthfund.org/publicati...)

There are several literature reviews of models that integrate health care and social services (bluecrossmafoundation.org/site... and commonwealthfund.org/sites/def...). These reviews, on the whole, demonstrate that models offering select social services like housing, nutrition, and care management, for patients that need them can reduce costly forms of health care utilization, improve patient outcomes, and even result in a return-on-investment. The Commonwealth Fund's review in particular found that more research is needed on the effects of offering non-emergency medical transportation for patients.

This is an important question especially given all the issues in today’s environment about clinician burnout. This cannot just be added onto all the tasks that clinicians face in productivity driven clinical environments. The screening workflows have to be well thought out. At Rush University Medical Center we have taken an approach not to screen unless we have built in resources to respond to the social needs of our patients. This required significant institutional investment to build an infrastructure to support social need workflows. This will not work if this is just another demand on busy clinicians. But if that support exists clinicians will buy in.

Health systems can generate clinician buy-in by sharing the evidence on the potential return-on-investment and patient health benefits associated with with addressing SDoH. The Commonwealth Fund created a Return-on-Investment calculator (commonwealthfund.org/roi-calcu...) and an evidence review on the ROI for addressing SDoH (commonwealthfund.org/sites/def...) that health systems could use in this process.

In addition, as frontline providers, clinicians likely know the impact social determinants have on their patients because they see it every day. Health systems should value this on-the-ground knowledge and ensure any processes targeting social needs of patients are co-designed with clinicians - both to generate buy-in and to ensure their efforts are practical and actionable.

Finally, it's important that health systems share with clinicians that the burden of addressing patients' social needs will not be placed solely on them and work with clinicians to identify what supports and trainings they need to be successful.

Addressing SDoH within the clinical workflow is critical to generate clinician buy-in. There are a wide variety of community-based organizations that address social needs and/or determinants. See this one innovative example from the South Side of Chicago where a e-prescribing model was used to link patients with the social supports they needed: healthaffairs.org/doi/10.1377/...

To meaningfully reform the health care system, lower costs, and improve health outcomes, we need to address the upstream social factors that determine the majority of health. Left unaddressed, these powerful forces like poverty and racism will hinder any progress the health system makes. By working to improve the conditions in which communities live, work, and play, health care reform can maximize its potential to achieve the triple aim.

I do not think there is one "vital sign" but many. At our institution, depending on the population, we are screening for ACES, depression, primary care access, food, housing, transportation and utility security. That said, there seem to be hierarchies of social needs and for those who have especially high needs these needs seem to cluster together. For example,someone who is homeless is also likely to be hungry. In general 30% of our urban mixed payer population screen positive for one SDoH and that is most often food insecurity.

On a population level, we have found that median neighborhood income is most linearly correlated to overall health outcomes.

We are currently trying to use machine learning to identify prior to a visit, which patients would most likely benefit from a SDoH screen so our screening is most effective.

Thank you Dr. Ansell. Do you know of any research combining median neighborhood income, food desert mapping and walkability scores?

I agree no single metric will suffice. We at 3M have developed a composite score of SDOH measures from several publically-available datasets at a Census Tract level. We are presently using over two-dozen variables organized around the SDOH Domains presented in Healthy People 2020: (1) Economic Stability, (2) Education, (3) Health and Health Care, (4) Neighborhood and Built Environment, and (5) Social and Community Context. Specific measures include income, education, health insurance coverage, food security, crime and violence, environmental quality, and others. We generally run the model at a state-level for payer clients and relate neighborhoods to state averages.

Our research shows the prevalence and importance of specific SDOH drivers can vary by neighborhood. This points toward defining local interventions as a productive strategy. Some neighborhoods may need better access to transportation; some may need improved food access.

Very interesting Paul. I would love to learn more about what you've done with your SDOH composite score at 3M. Please feel free to e-mail me at docmoyo@welfie.com

For years, SDoH efforts were hampered by a lack of standards, measures, best practices, and tools for SDoH data. Collecting and using it has been difficult, and well-meaning coalitions have been forced to create home-grown solutions, which complicates analyses and comparisons.

Fortunately, organizational thought leaders have been driving improvement in these areas. For example, RWJF’s ‘Evidence for Action’ program (which generates evidence to promote population health and health equity) rests on their ‘Action Framework’ measure set which was designed to mobilize action and exhibit the interdependence of health’s socioecological determinants. By design, it includes measures absent from other national sets and supports non-traditional inquiry methodologies.

Another example is the National Academies of Medicine’s Vital Signs: Core Metrics for Health and Health Care Progress. This report proposes core measures that together constitute the most vital signs for the nation’s health and health care (along with standardized domains and benchmarks). Vital Signs also promotes an expanded view of health - while four of its domains were already widely assessed, the rest are new.

Standards and tools for SDoH data collection are also emerging. One example is PRAPARE, the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. It is a national effort to promote a standardized risk assessment protocol to assess and act on an individual’s SDoH-related barriers and is integrated with electronic health records to facilitate assessment and intervention.

Both the companies designing the technologies and academic health centers have the responsibility of making sure these technologies are effective, impactful and unbiased.

There are a number of resource referral platforms that support healthcare systems to address patients' health-related social needs (this is a useful review from UCSF SIREN -- sirenetwork.ucsf.edu/tools-res...). Integrated Data Systems (aisp.upenn.edu/integrated-data...) are often used to collect and analyze data to inform community-level efforts to improve social conditions and some of these involve healthcare. Platforms like Streetwyze (streetwyze.com/) and Partner (visiblenetworklabs.com/intro-t...) support place-based and network-based approaches to health, respectively.
Each tool is designed for a different purpose and should be validated for that purpose by the people who are meant to benefit. Measures of success must be co-created or co-selected with those beneficiaries. With regard to health related social needs, it is very clear that tracking "closed loop referrals" is insufficient, but a straightforward, broadly applicable approach to measuring social health outcomes for whole people or whole households has yet to emerge.

I agree with Dr. Moyo, but would add patients and healthcare institutions to his list. Research and user testing by companies themselves are necessary, but not sufficient to understand the full risks and benefits in real world use. Innovation networks like AVIA (aviahealthinnovation.com/) can help healthcare organizations understand likely value in their context. I'm not aware of independent patient or consumer groups that do similar work, but it would be very helpful if one existed.

In an ideal world, all policies and programs used to promote health equity and address SDoH would be evidence-based and stem from rigorous research results, and the organizations delivering evidence-based solutions would validate they are achieving the desired outcomes.

Despite being ideal, it is not easy to achieve due to the significant gaps in evidence about SDoH interventions.

Because of this, SDoH initiatives should also strive to generate new knowledge - knowledge that can enhance our understanding of SDoH, how impacts differ across populations and settings, and effective ways to disrupt or eliminate them. Initiatives should also expand the evidence about the interventions themselves, including what specific components and operating models worked best under different circumstances and what their economic impacts were.

ChroniCare (chroni.care) helps providers address SDoH by making it easy to offer remote care coordination services to their patients. Some of the most impactful remote interventions focus on addressing environmental factors including gaps in housing, food, and transportation.

Additionally, Aunt Bertha (auntbertha.com) offers a comprehensive list of home and community based services in most communities across the country.

At Rush University Medical Center we have integrated SDoH screening in EPIC with NowPow and increasingly have been testing "closed loop" referrals to evaluate the effectiveness of this integration. For example we have referred patients without insurance and without primary care using this closed loop methodology to receive primary care follow up by Rush physicians at a community health center. This system has resulted in a significant reduction in 30 day readmission rates. The closed loop piece has made it much more efficient for the patient navigator at Rush to connect with the care-coordinator at the free clinic, without having to call on the phone. It's decreased the turn around time for the patient to receive a post discharge appointment.

The Center for Healthcare Strategies created a database of digital health products for complex patients, several of which address social needs: chcs.org/digital-health-produc.... The database includes information on results to date and current users.

One listed here is Healthify, a digital platform that helps health systems, payers, local government, and community-based organizations create virtual community networks so they can systematically identify and refer patients to social services, as well as track population-level outcomes. Early results indicate high rates of completion of referrals: chcs.org/digital-health-produc...

UniteUs are doing some great things with regards to SDOH I think, and have recently partnered with Kaiser. uniteus.com

I feel compelled to highlight the incredible work my team has been doing with healthcare organizations focused on SDoH. Our mission at ClosedLoop is to make it easy for healthcare organizations to use data science to promote health and reduce costs, and my team knows first-hand how rewarding it is to help build solutions that actually begin to address SDoH. This is because many of the organizations with whom we work have patients who are adversely impacted by SDoH.

One such organization is a Medicaid ACO in Chicago. Their goal was to improve the effectiveness of their care management team by predicting which patients were going to be in the top 5% of utilizers. They had HRA and SDoH data that our team used as a starting point, but what we found was other data assets provided incremental value for predicting who was going to be high risk / high cost. After layering on multiple data sources (HRA, SDoH, Claims, ADT, etc.), our ability to predict high risk patients increased by 63% compared to their old approach.

Today, these predictions power their care management teams so they can focus on the patients that need additional care and resources the most. They also show how data on social determinants can be strategically included to improve health outcomes. Our big takeaway - use all your available healthcare data when making predictions!