Connecting Social Needs to Health Care for Better Outcomes

midwife and patient

By Nora OBrien-Suric, PhD

Addressing the social determinants of health—a person’s needs related to community support systems, in-home services, transportation, and other social or economic factors—is an important part of improving the overall health and well-being of people in our community. However, institutional barriers such as payment models and workforce challenges have traditionally made it difficult for social needs to be considered part of health care.

The Health Foundation is partnering on a number of initiatives that help remove those barriers and integrate social needs into health care.

In 2019, we helped fund a report published by the National Academies of Sciences, Engineering and Medicine (NASEM) that examined the role of social determinants of health in care delivery and offered recommendations to improve the ability of health systems to work with social care providers. Read the report here. 

The NASEM report’s recommendations are in line with a number of ongoing initiatives the Health Foundation is supporting to help integrate social care and health care.

A New Approach to Care
Collaboration is a critical part of addressing the social determinants of health. Across the country, community-based organizations are embarking on partnerships with health care systems that improve care coordination, reduce unnecessary hospitalizations, and attempt to address the root causes of some health issues.

One local example is the WNY Integrated Care Collaborative (WNYICC), a multi-county network of governmental agencies and community-based organizations that was created with support from the Health Foundation and The John A. Hartford Foundation. WNYICC’s network is strategically positioned to respond to regional opportunities to advance community-based care coordinated in collaboration with hospitals and insurance providers.

Many community-based organizations, especially those with limited staff or financial resources, face challenges with the technical or business aspects of working with large health systems and insurance providers. Training to address these issues will be a vital part of any effort to integrate social needs into health care systems. The Health Foundation has supported training programs like this for WNYICC participating organizations, and we anticipate the opportunity to support similar programs as this trend continues statewide and nationally.

The Role of Policy
In addition to business model changes, legislative and regulatory efforts can play a role in integrating social care needs into health care. As one example, the NASEM report recommends encouraging policymakers and elected officials to support financing options that would allow social care providers to be reimbursed for their services.

Another example of this type of legislative effort is the CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic) Care Act, a federal law that allows for coverage of transportation, nutrition and housing services for the chronically ill who receive Medicare Advantage benefits. This is a great example of regulatory change that can help integrate social care into health care systems.

Other policy efforts in New York State include the Delivery System Reform Incentive Payment program, or DSRIP, a program designed to encourage community-level collaborations to help prevent unnecessary hospitalizations, improve outcomes and reduce costs.

In addition, Governor Andrew Cuomo’s Health Across All Policies/Age-Friendly NYS initiatives are working toward integrating health considerations into policymaking across all sectors to address the social determinants of health and improve livability. The Health Foundation is a partner on these initiatives and recently awarded grants to three New York counties to support Age-Friendly Centers of Excellence. Through collaboration between local and state government and community partners, these programs will work to address social determinants in each county, with the goal of improving conditions for people of all ages.

How Health Systems Can Adjust
Even while this important progress is made, there are additional opportunities for health systems to address social determinants of health. The NASEM report notes five activities health systems can engage in to better integrate social needs into care delivery: awareness, adjustment, assistance, alignment and advocacy:

  • Awareness activities identify the social risks and assets of defined patients and populations.
  • Adjustment activities alter clinical care to accommodate identified social barriers.
  • Assistance activities reduce social risk by connecting patients with social care resources.
  • Alignment activities enable health care systems to understand their communities’ existing social care assets, facilitate synergies, and invest in and deploy them to positively affect health outcomes.
  • Advocacy activities bring together as partners health care and social care organizations to promote policies that facilitate the creation and redeployment of resources to address health and social needs.

The Future of Health Care Collaboration
These partnerships are part of a national movement that is already showing results in improving health outcomes and the care experience while reducing per capita costs. We are encouraged by the recent progress made in recognizing the role of social needs in health care, and we look forward to continuing to support and partner on initiatives that make it easier for care providers to address those needs.