rwjf-tag: Addressing social determinants of health

Health Research and Education Trust. (2012). Managing population health: The role of the hospital. Chicago, IL: American Hospital Association.

This guide is designed to define population health, describe strategies to improve the health of a hospital’s patient population, inform leaders why these initiatives are essential, and explore potential partnerships that can help achieve the desired goal as illustrated in the diagram below. Short case examples provide supporting evidence and show that every health care… Read more »

Kotelchuck, R., Lowenstein, D., & Tobin, J.N. (2011). Community health centers and community development financial institutions: Joining forces to address determinants of health. Health Affairs, 30(11).

This article discusses how Community Development Financial Institutions (CDFIs) and Community Health Centers (CHCs) make natural allies and have been working together. This article reviews the most recent trends in these two sectors and explores opportunities for further collaboration to transform the health and well-being of the nation’s low-income communities.

Huff, C. (2010). Community partnerships. Trustee, 63(9), 6-10.

This article describes community health partnerships between hospitals and community organizations, and discusses the role of hospitals and other community organizations in these initiatives. These partnerships include an educational program focusing on African-American women and breast health, a program to address transportation difficulties for getting to medical appointments, and a hospital working with faith-based organizations… Read more »

Taylor, L.A., Coyle, C.E., Nudumele, C., Rogan, E., Caravan, M., Curry, L, & Bradley, E.H. (2015). Leveraging the social determinants of health: What works? Blue Cross Blue Shield of Massachusetts Foundation.

This report outlines the importance of addressing the social determinants of health to improve health outcomes. Evidence-based interventions (including partnerships with Blue Cross Blue Shield health plan) that can effectively address the social determinants of health are discussed.

Bachrach, D., Pfister, H., Wallis, K., & Lipson, M. (2014). Addressing patients’ social needs: An emerging case for provider investment. New York, NY: The Commonwealth Fund.

This report explores the impact of social factors on patient health and health care costs, and the growing relevance of such factors in today’s health care environment. Informed by published research and interviews with more than 25 experts, we point out the direct and indirect economic benefits that may inure to providers who address patients’… Read more »

Cunningham, M., Pergmit, M., McDaniel, M., Gearing, M., Zhang, S., & Howell, B. (2014). Supportive housing for high-need families in the child welfare system. Washington, DC: Urban Institute.

This brief describes the purpose and design of the Partnership to Demonstrate the Effectiveness of Supportive Housing for Families in the Child Welfare System federal demonstration and profiles the five program sites.Supportive Housing is an intervention that combines affordable housing with intensive wrap around services. The intervention has been successful with hard to serve populations,… Read more »

Meiners, M.R., Mokler, P.M., Kasunic, M.L., Hawthornthwaite, S., Foster, S., Scheer, D., & Maldonado, A.M. (2014). Insights from a pilot program to integrate medical and social services. Home Health Care Quarterly, 33(3),121-136.

This study examines lessons learned from the design, implementation, and early results of an integrated managed care pilot program linking member benefits of a Medicare-Medicaid health care plan with community services and supports. The health plan’s average monthly costs for members receiving an assessment and services declined by an economically meaningful, statistically significant amount in… Read more »

McGinnis, T., Crawford, M., & Somers, S. (2014, July). State policy framework for integrating health and social services. New York, NY: The Commonwealth Fund.

This issue brief describes three essential components for integrating health, including physical and behavioral health services and public health, and social services: 1) a coordinating mechanism; 2) quality measurement and data-sharing tools; and 3) aligned financing and payment. It also presents a five-step policy framework to help states move beyond isolated pilot efforts and establish… Read more »

The Menges Group. (2014, June). Positively impacting social determinants of health: How safety net health plans lead the way. The Association for Community Affiliated Plans.

This report seeks to follow the five key areas of social determinants as outlined by Healthy People 2020, an initiative by the Department of Health and Human Services. The report describes programs in which the Association for Community Affiliated Press (ACAP) health plans are innovatively and positively impacting the other key areas of social determinants… Read more »

Chokshi, D., Singh, P., & Stine, N.W. (2014, April 16). Using community health trusts to address social determinants of health [Web log post].

Although health care systems deliver care for patients with chronic diseases, most medical centers are ill-equipped to tackle the social determinants of health themselves. This is a significant blind spot for the vision of a patient-centered, population health–driven system, and one that community health trusts could help address. In this article, the authors offer Community… Read more »

Kindig, D.A., & Isham, G. (2014). Population health improvement: A community health business model that engages partners in all sectors. Frontiers of Health Services Management, 30(4), 3-20.

In this article, the authors suggest the development of multisectoral community health business partnership models. Such collaborative efforts are needed by sectors and actors not accustomed to working together. Healthcare executives can play important leadership roles in fostering or supporting such partnerships in local and national arenas where they have influence. The authors develop the… Read more »

Shrimali, B., Luginbuhl, J., Malin, C., Fournoy, R., & Siegel, R. (2014). The building blocks collaborative: Advancing a life couse approach to health equity through multi-sector collaboration. Maternal and Child Health Journal, 18(2), 373-379.

This article describes the “Building Blocks Collaborative (BBC)” launched by the Alameda County Public Health Department (ACPHD) in California. The program focuses on young children in low income communities and was developed to improve health equity by improving community conditions that affect health and focusing on certain developmental periods in a child’s life. The authors… Read more »

Mahadevan, R., & Houston, R. (2015). Supporting social service delivery through Medicaid accountable care organizations: Early state efforts. Hamilton, NJ: Center for Health Care Strategies.

This brief highlights the initial efforts of seven states — Colorado, Maine, Minnesota, New York, Oregon, Vermont, and Washington — that participated in CHCS’ Medicaid ACO Learning Collaborative. These states each have sought to incorporate social services into their existing or emerging Medicaid ACO models. The brief outlines key themes and considerations from these early… Read more »

Spencer, A., Lloyd, J., & McGinnis, T. (2015). Using Medicaid resources to pay for health-related supportive services: Early lessons. Hamilton, NJ: Center for Health Care Strategies.

Building off previous work by the Center for Health Care Strategies (CHCS), this brief examines how these states are using Medicaid funding for supportive services as part of broader delivery system and payment reform efforts. CHCS conducted interviews with state officials, community providers, and national experts to identify how these Medicaid programs are determining the… Read more »

Casalino, L.P., Erb, N., Joshi, M.S., & Shortell, S.M. (2014). Accountable care organizations and population health organizations. Journal of Health Politics, Policy, and Law, 40(4), 821-837.

This article discusses how Accountable Care Organizations (ACOs) and hospitals might work together toward improving population health. As hospitals become more interested in population health and enter into population health activities, they need to take care to not obscure the term and impede progress related to improving social determinants of health. ACOs and hospitals could… Read more »

Corrigan, J., Fisher, E., & Heiser, S. (2015). Hospital community benefit programs increasing benefits to communities. Journal of the American Medical Association, 313(12), 1211-1212.

In this viewpoint, the authors suggest that a modest reorientation of Hospital Community Benefit Programs (HCBPs) could help accelerate the development of successful regional health improvement initiatives. This article argues that delivery reforms alone cannot produce the cost savings required to sustain the healthcare industry; the industry must address the social determinants of health. HCBPs… Read more »

Crawford, M., McGinnis, T., Auerbach, J., & Golden, K. (2015). Population health in Medicaid delivery system reforms. New York, NY: Milbank Memorial Fund.

This issue brief focuses on strategies that inform Accountable Care Organization (ACO) design and governance structures, program components, metrics, and information-sharing mechanisms—and it includes some promising early examples of states working to embed population health strategies in Medicaid ACOs. It highlights both the challenges states have faced and the strategies that have been used. It… Read more »

Garg, A., Toy, S., Tripodis, Y., Silverstein, M., & Freeman, E. (2015). Addressing social determinants of health at well child care visits: A cluster RCT. Pediatrics, 135(2):,296-304.

This study evaluated the effect of a clinic-based screening and referral system (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE]) on families’ receipt of community-based resources for unmet basic needs. The authors conducted a cluster randomized controlled trial at 8 urban community health centers, recruiting mothers of healthy infants. In the 4… Read more »

Helman, H.J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Social determinants of health are the conditions in which people are born, grow, live, work and age that shape health. This brief provides an overview of social determinants of health and emerging initiatives to address them. It shows: social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social… Read more »

Henize, A.W., Beck, A.F., Klein, M.D., Adams, M., & Kahn, R.S. (2015). A road map to address the social determinants of health through community collaboration. Pediatrics, 136(4), 993-10001.

In this article, the authors use Maslow’s Hierarchy of Needs to demonstrate how partnerships between primary pediatric care physicians and community-based organizations can improve health outcomes. A partnership with a legal-aid group and food bank are described and some suggestions on how to establish similar partnerships in other locations are provided. There is a brief… Read more »

Cassidy, A. (2016, October 14). Health Policy Brief: Medicaid and permanent supportive housing: Medicaid offers opportunities to address supportive housing needs, but challenges remain. Washington, DC: Health Affairs.

This article provides a description of the legal landscape around how Medicaid might finance housing supports. Current housing methods to provide housing are focused on acute care, and individuals often lose that housing either when the acute issue is cleared up or when they fail to perfectly adhere to something like a no-drugs-or-drinking agreement.

Moses, K., Hamblin, A., & Somers, S. (2016, January). Supportive housing for chronically homeless Medicaid enrollees: State strategies. Hamilton, NJ: Center for Health Care Strategies.

In July 2015, the Center for Health Care Strategies (CHCS) convened state Medicaid officials; federal policymakers from the Department of Health and Human Services, the Department of Housing and Urban Development, the Office of Management and Budget, and the United States Interagency Council on Homelessness; and experts in the fields of managed care, housing, and… Read more »

Segal, L.M., De Biasi, A., Lieberman, D.A., Olson, G., & Ilakkuvan, V. (2016, October). Blueprint for a health America 2016: Policy priorities for the next administration and Congress. Washington, DC: Trust for America’s Health.

This report highlights high-impact policies that could help spare millions of Americans from preventable health problems and save billions in avoidable healthcare costs. The report highlights pressing crises and how investments could yield positive returns on investment by adopting proven health strategies. The Blueprint highlights leading evidence-based strategies for improving health and policy – and… Read more »

Sparer, M., & Muenning, P. (2016, May). (Re)defining the healthcare delivery system: The role of social services. KPMG Government Institute & the Mailman School of Public Health at Columbia University.

In May 2015, the Mailman School of Public Health, through its Department of Health Policy and Management (HPM), and KPMG LLP (KPMG) jointly hosted a conference to consider key questions raised by New York’s Delivery System Reform Incentive Payment (DSRIP) and similar initiatives that seek to bridge the gap between social services and health. The… Read more »

Rubin, J., Taylor, J., Krapels, J., Sutherland, A., Felician, M., Liu, J., … Rohr, C. (2016). Are better health outcomes related to social expenditure? A cross-national empirical analysis of social expenditure and population health measures. Santa Monica, CA: RAND Europe.

This report presents findings from a longitudinal cross-national study on social spending, health outcomes, and wider societal factors. The study confirmed earlier findings of a positive association between higher social spending and improved health outcomes, even when this is tested in many different ways. Public social expenditure by governments seems to have a particularly strong… Read more »

Steiner, T., & Tynan, W.D. (2016). Social determinants and collaborative health care: Improved outcomes, reduced costs. Deloitte.

This paper reviews some of the individual and collective impacts that physical health, behavioral health, and social determinants have on individuals and the US health system; examines how collaborative care models can help to improve outcomes and lower costs; discusses challenges to implementing integrated care; and suggests implications and opportunities for health plans and states.

Kottke, T.E., Stiefel, M., & Pronk, N.P. (2016). Well-being in all policies: Promoting cross-sectoral collaborations to improve people’s lives. Preventing Chronic Diseases, 14(13), E52.

In this article, the authors suggest that in the US the expression “well-being in all policies” be used instead of “health in all policies.” The authors argue that adopting this convention could avoid the problems caused when health care policy is conflated with health policy. It may also increase the willingness of policy makers in… Read more »

Dayton Children’s Hospital. (2016, September 9). Innovative social needs intervention at Dayton Children’s Hospital connects patients to community resources [Press release].

This website article explains how Dayton Children’s Hospital is addressing unmet social needs like food, transportation, and housing by connecting families in need with community resources. To address these issues, Dayton Children’s Hospital Center for Child Health and Wellness launched a program called the Family Resource Connection to screen patient families for unmet social needs… Read more »

Demilto, L., & Nakashian, M. (2016). Using social determinants of health data to improve health care and health: A learning report. M. McKaughan (Ed.). Washington, DC: Robert Wood Johnson Foundation.

This report aims to provide the Robert Wood Johnson Foundation (RWJF) and other health foundations with a perspective on the emerging intersection of social determinants of health (SDOH), health care systems, and social and other services. These fields intersect in how and what data are collected, and in ways the data are used to improve… Read more »

Norris, T., & Howard, T. (2016). Can hospitals heal America’s communities? “All in for mission” is the emerging model for impact. Washington, DC: Democracy Collaborative.

This paper examines the possibilities and explores how “all in for mission” is the emerging healthcare model, and discusses how some healthcare systems are expanding their focus to address the social determinants of health. The authors use the term “anchor mission” to describe hospital systems that are working to improve the community surrounding their institutions…. Read more »

Subica, A.M., Grills, C.T., Douglas, J.A., & Villaneuva, S. (2016). Communities of color creating healthy environments to combat childhood obesity. American Journal of Public Health, 106(1), 78-86.

In this article, the authors present a novel 3-lens prescription for using community organizing to treat these determinants in communities of color based on the Robert Wood Johnson Foundation’s Communities Creating Healthy Environments initiative, the first national project to combat childhood obesity in communities of color using community organizing strategies. The lenses–Social Justice, Culture-Place, and… Read more »

Miller, E., Nath, T., & Line, L. (2017). Working together toward better health outcomes. Hamilton, NJ: Partnership for Healthy Outcomes.

In this report, the Partnership for Healthy Outcomes – comprised of Nonprofit Finance Fund (NFF), Center for Healthcare Strategies (CHCS), and the Alliance for Strong Families and Communities (Alliance), with support from the Robert Wood Johnson Foundation (RWJF) – set out to capture and analyze the lessons emerging in this dynamic space, as organizations explore… Read more »

Jones, A., Lemak, C.H., Lulias, C., Burkard, T., McDowell, B., & Severson, K. (2017). Predictive value of screening for addressable social risk factors. Journal of Community Medicine and Public Health Care, 4, 030.

This study aimed to evaluate whether a screening assessment tool that identifies medical and social risk factors is predictive of healthcare costs in the absence of claims data and to evaluate the effectiveness of screening for social factors to target high cost beneficiaries. A retrospective study evaluating medical and pharmacy claims costs for newly-eligible Medicaid… Read more »

National Quality Forum. (2017, December). A framework for Medicaid programs to address social determinants of health: Food insecurity and housing instability. Washington, DC: Author.

This report describes a framework for state Medicaid programs to support the collection of social determinants of health data and the integration of health and nonhealth services, using food insecurity and housing instability as illustrative examples. In collaboration with the Centers for Medicare & Medicaid Services (CMS), the National Quality Forum (NQF) convened an Expert… Read more »

Fraze, T., Lewis, V.A., Rodrigues, H.P., & Fisher, E.S. (2016). Housing, transportation, and food: How ACOs seek to improve population health by addressing nonmedical needs of patients. Health Affairs, 35(11), 2109-2115.

Using qualitative interviews with Accountable Care Organizations (ACOs) leaders and site visits, this study examines how ACOs addressed the nonmedical needs of their patients, and the extent to which they did so. The authors developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration and found that the… Read more »