What are the social determinants of health?
Social determinants of health are the conditions during which people are born, grow, live, work and age. They include factors such as. socioeconomic status, education, neighborhood, and physical environment, employment, and social support networks, also as access to health care.
Addressing social determinants of health is vital for improving health and reducing health disparities. Though health care is important to health, it’s a comparatively weak health determinant.
Research shows that health outcomes are driven by an array of things, including underlying genetics, health behaviors, social and environmental factors, and health care.
Why are social determinants of health important?
While there’s currently no consensus within the research on the magnitude of the relative contributions of every one of those factors to health. studies suggest that health behaviors, like smoking, diet, and exercise, and social and economic factors are the first drivers of health outcomes,
and social and economic factors can shape individuals’ health behaviors.
For instance, children born to oldsters who haven’t completed high school are more likely to measure in an environment that poses barriers to health like lack of safety, exposed garbage, and substandard housing.
There are few things you keep in mind, less likely to possess access to sidewalks, parks or playgrounds, recreation centers, or a library.
Further, evidence shows that stress negatively so affects health across the lifespan5 which environmental factors may have multi-generational impacts. Addressing social determinants of health isn’t only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.
Social determinants of health are the conditions during which people are born, grow, live, work, and age that shape health. This brief provides a summary of social determinants of health and emerging initiatives to deal with them.
Social determinants of health include factors, what are they are? socioeconomic status, education, neighborhood, and physical environment, employment, and social support networks, also as access to health care. Addressing social determinants of health is vital for improving health and reducing longstanding disparities in health and health care.
Examples of social determinants include:
- Availability of resources to meet daily needs (e.g., safe housing and local food markets)
- Access to educational, economic, and job opportunities
- Access to health care services
- Quality of education and job training
- Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
- Transportation options
- Public safety
- Social support
- Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
- Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
- Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
- Residential segregation
- Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
Examples of physical determinants include:
- The natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
- The built environment, such as buildings, sidewalks, bike lanes, and roads
- Worksites, schools, and recreational settings
- Housing and community design
- Exposure to toxic substances and other physical hazards
- Physical barriers, especially for people with disabilities
- Aesthetic elements (e.g., good lighting, trees, and benches)
There are a growing number of initiatives to deal with social determinants of health within and out of doors of the health care system. Outside of the health care system, initiatives seek to shape policies and practices in non-health sectors in ways during which promote health and health equity.
Within the health care system, there are multi-payer federal and state initiatives also as Medicaid-specific initiatives focused on addressing social needs.
These include models under the middle for Medicare and Medicaid Innovation, Medicaid delivery system, and payment reform initiatives and options under Medicaid.
Managed-care plans and providers are also engaged in activities to spot and address social needs. for instance, 19 states required Medicaid managed care plans to screen for and/or provide referrals for social needs in 2017, and a recent survey of Medicaid managed care plans found that nearly all (91%) responding plans reported activities to deal with social determinants of health.
Many challenges remain to affect social determinants of health, and new directions pursued by the Trump Administration could limit resources and initiatives focused on these efforts.
The Trump Administration is pursuing a spread of the latest policies and policy changes, including enforcing and expanding work requirements associated with public programs and reducing funding for prevention and public health. These changes may limit individuals’ access to assistance programs to deal with health and other needs and reduce resources available to deal with social determinants of health.
Social Determinants of Health Introduction
Efforts to enhance health within the U.S. country have looked to the health care system because of the key driver of health and health outcomes. Also, there has been increased recognition that improving health and achieving health equity would require broader approaches that address social, economic, and environmental factors that influence health. This brief provides a summary of those social determinants of health and discusses emerging initiatives to deal with them.
What are Social Determinants of Health?
Social determinants of health are the conditions during which people are born, grow, live, work and age. They include factors like socioeconomic status, education, neighborhood, and physical environment, employment, and social support networks, also as access to health care.
Addressing social determinants of health is vital for improving health and reducing health disparities. Though health care is essential to health, it’s a comparatively weak health determinant. Research shows that health outcomes are driven by an array of things, including underlying genetics, health behaviors, social and environmental factors, and health care.
While there’s currently no consensus within the research on the magnitude of the relative contributions of every one of those factors to health, studies suggest that health behaviors, like smoking, diet, and exercise, and social and economic factors are the first drivers of health outcomes, and social and economic factors can shape individuals’ health behaviors.
For instance, children born to oldsters who haven’t completed high school are more likely to measure in an environment that poses barriers to health like lack of safety, exposed garbage, and substandard housing. There are few things you keep in mind, less likely to possess access to sidewalks, parks or playgrounds, recreation centers, or a library.4 Further, evidence shows that stress negatively so affects health across the lifespan5 which environmental factors may have multi-generational impacts.
Addressing social determinants of health isn’t only crucial for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.
Initiatives to deal with Social Determinants of Health
A growing number of initiatives are emerging to deal with social determinants of health. a number of these initiatives seek to extend the main target on health in non-health sectors, while others specialize in having the health care system address broader social and environmental factors that influence health.
Focus on Health in Non-Health Sectors
Here we talking about Policies and practices in non-health sectors that have impacts on health and health equity. for instance. and the supply and accessibility of public transportation affect access to employment, affordable healthy foods, health care, and other important drivers of health and wellness.
Nutrition programs and policies also can promote health, for instance, by supporting healthier corner stores in low-income communities, farm to high school programs and community and faculty gardens, and thru broader efforts to support the assembly and consumption of healthy foods. the supply of infancy education to children in low-income families and communities of color helps to scale back achievement gaps, improve the health of low-income students, and promote health equity.
“Health altogether Policies” is an approach that comes with health considerations into decision-making across sectors and policy areas. A Health altogether Policies approach identifies the ways during which decisions in multiple sectors affect health, and the way improved health can support the goals of those multiple sectors.
It is engaging to diverse partners and stakeholders to figure together to market health, equity, and sustainability, and simultaneously advance other goals like promoting job creation and economic stability, transportation access and mobility, a robust agricultural system, and improved educational attainment.
States and localities are utilizing the Health altogether Policies approach through task forces and workgroups focused on bringing together leaders across agencies and therefore the community to collaborate and prioritize the attention on health and health equity.12 At the federal level, the Affordable Care Act (ACA) established the National Prevention Council, which brings together senior leadership from 20 federal departments, agencies, and offices, who worked with the Prevention Advisory Group, stakeholders, and therefore the public to develop the National Prevention Strategy.
Place-based initiatives specialise in implementing cross-sector strategies to enhance health in neighborhoods or communities with poor health outcomes. There continues to be growing recognition of the connection between neighborhoods and health, with postcode understood to be a stronger predictor of a person’s health than their ordering .
A variety of initiatives specialize in implementing coordinated strategies across different sectors in neighborhoods with social, economic, and environmental barriers that cause poor health outcomes and health disparities. for instance, the Harlem Children’s Zone (HCZ) project focuses on children within a 100-block area in Central Harlem that had chronic disease and infant deathrate rates that exceeded rates for several other sections of the town also as high rates of poverty and unemployment. HCZ seeks to enhance the tutorial, economic, and health outcomes of the community through a broad range of family-based, welfare work, and health programs.
Addressing Social Determinants within the Health Care System
In addition to the growing movement to include health impact/outcome considerations into non-health policy areas, there also are emerging efforts to deal with non-medical, social determinants of health within the context of the health healthcare delivery system. These include multi-payer federal and state initiatives, Medicaid initiatives led by states or by health plans, also as provider-level activities focused on identifying and addressing the non-medical, social needs of their patients.
FEDERAL AND STATE INITIATIVES
In 2016, the middle for Medicare and Medicaid Innovation (CMMI), which was established by the ACA, announced a replacement “Accountable Health Communities” model focused on connecting Medicare and Medicaid beneficiaries with community services to deal with health-related social needs.
The model provides funding to check whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services will affect health costs and reduce inpatient and outpatient utilization.
In 2017, CMMI awarded 32 grants to organizations to participate within the model over a five-year period. Twelve awardees will provide navigation services to help high-risk beneficiaries with accessing community services and 20 awardees will encourage partner alignment to make sure that community services are available and aware of the requirements of enrollees.
Through the CMMI State Innovation Models Initiative (SIM), a variety of states are engaged in multi-payer delivery and payment reforms that include attention to population health and recognize the role of social determinants. SIM may be a CMMI initiative that gives financial and technical support to states for the event and testing of state-led, multi-payer health care payment and repair delivery models that aim to enhance health system performance, increase the quality of care, and reduce costs.
To date, the SIM initiative has awarded nearly $950 million in grants to cover half of the states to style and/or test innovative payment and delivery models. As a part of the second round of SIM grant awards, states are required to develop a statewide decision to improve population health. States that received Round 2 grants are pursuing a spread of approaches to spot and prioritize population health needs; link clinical, public health, and community-based resources; and address social determinants of health.
All 11 states that received Round 2 SIM Testing grants decide to establish links between medical care and community-based organizations and social services.15 for instance, Ohio is using SIM funds, in part, to support a comprehensive medical care (CPC) program during which medical care providers connect patients with needed social services and community-based prevention programs.
As of December 2017, 96 practices were participating within the CPC program. Connecticut’s SIM model seeks to market a complicated Medical Home model that will address the big selection of individuals’ needs, including environmental and socioeconomic factors that contribute to their ongoing health.
one of the numbers of the states with Round 2 testing grants are creating local or regional entities to spot and address population health needs and establish links to community services. for instance, Washington State established nine regional “Accountable Communities of Health,” which can compile local stakeholders from multiple sectors to work out priorities for and implement regional health improvement projects.
Delaware plans to implement ten “Healthy Neighborhoods” across the state which will specialize in priorities like healthy lifestyles, maternal and child health, psychological state and addiction, and chronic disease prevention and management. Idaho is creating seven “Regional Health Collaboratives” through the state’s public health districts which will support local medical care practices in Patient-Centered Medical Home transformation and make formal referral and feedback protocols to link medical and social services providers
second-round testing grant states are also pursuing a variety of other activities focused on population health and social determinants. a number of these activities include using population health measures to qualify practices as medical homes or determine incentive payments, incorporating the use of community doctors in care teams, and extracting data collection and analysis infrastructure focused on population health and social determinants of health.
Delivery System and Payment Reform
A number of delivery and payment reform initiatives within Medicaid include attention on linking health care and social needs. In many cases, these efforts are a part of the larger multi-payer SIM models noted above and should be part of Section 1115 Medicaid demonstration waivers. for instance, Colorado and Oregon are implementing Medicaid payment and delivery models that provide care through regional entities that specialize in the mixing of physical, behavioral, and social services also as community engagement and collaboration.
In Oregon, each Coordinated Care Organization (or “CCO”) is required to determine a community advisory council and develop a community health needs assessment. CCOs receive a worldwide payment for every enrollee, providing flexibility for CCOs to supply “health-related services” which supplement traditional covered Medicaid benefits and should target the social determinants of health.
Early experiences suggest that CCOs are connecting with community partners and starting to address social factors that influence health through a variety of projects. for instance, one CCO has funded a community doctor to assist link pregnant or parenting teens to health services and address other needs, like housing, food, and income. Another CCO worked with providers and therefore the local Meals on Wheels program to deliver meals to Medicaid enrollees discharged from the hospital who need food assistance as a part of their recovery.
An evaluation conducted by the Oregon Health & Science University’s Center for Health Systems Effectiveness released in 2017 found CCOs were related to reductions in spending growth and improvement in some quality domains. consistent with the evaluation, most CCOs believed health-related flexible services were effective at improving outcomes and reducing costs.
Similarly, in Colorado, the Regional Collaborative Organizations (RCCOs), which are paid a per member per month payment for enrollees, help connect individuals to community services through referral systems also as through targeted programs designed to deal with specific needs identified within the community.
A study published in 2017 comparing Oregon’s CCO program to Colorado’s RCCO program found that Colorado’s RCCO program generated comparable reductions in expenditures and inpatient care days.
Several other state Medicaid programs have launched Accountable Care Organization (ACO) models that always include population-based payments or total cost of care formulas, which can provide incentives for providers to deal with the broad needs of Medicaid beneficiaries, including the social determinants of health.
Some state Medicaid programs are supporting providers’ specialise in social determinants of health through “Delivery System Reform Incentive Payment” (DSRIP) initiatives.
DSRIP initiatives emerged under the Obama Administration as a part of Section 1115 Medicaid demonstration waivers.
DSRIP initiatives link Medicaid funding for eligible providers to process and performance metrics, which can involve addressing social needs and factors. for instance, in NY, provider systems may implement DSRIP projects aimed toward ensuring that folks have supportive housing. The state also has invested significant state dollars outside of its DSRIP waiver in housing stock to make sure that a far better supply of appropriate housing is out there.
In Texas, some providers have used DSRIP funds to put in refrigerators in homeless shelters to enhance individuals’ access to insulin. The California DSRIP waiver has increased the extent to which the general public hospital systems specialize in coordination with social services agencies and county-level welfare offices. To date, data on the results of DSRIP programs are limited, but a final federal evaluation report is scheduled for 2019.
Medicaid programs are also providing broader services to support health through the health homes option established by the ACA. Under this feature, states can establish health homes to coordinate look after people that have chronic conditions.
Health home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, also for referrals to community and social support services. Health home providers are often a delegated provider, a team of health professionals linked to a delegated provider, or a community health team. a complete of 21 states report that health homes were in situ within the financial year 2017.
A federally-funded evaluation of the health homes model found that the majority of providers reported big growth in their ability to attach patients to nonclinical social services and supports under the model, but that lack of stable housing and transportation were common problems for several enrollees that were difficult for providers to deal with insufficient affordable housing and rent support resources.
Housing and Employment Supports
Some states are providing housing support to Medicaid enrollees through a variety of optional state plan and waiver authorities. While states cannot use funds to buy room and board, funds can support a variety of housing-related activities, including referral, support services, and case management services that help connect and retain individuals in stable housing.
for instance, the Louisiana Department of Health formed a partnership with the Louisiana Housing Authority to determine a Permanent Supportive Housing (PSH) program with the twin goals of preventing and reducing homelessness and unnecessary institutionalization among people with disabilities.
Louisiana’s Medicaid program covers three phases of tenancy support services for Medicaid beneficiaries in permanent supportive housing: pre-tenancy services (housing search assistance, application assistance, etc.), move-in services, and ongoing tenancy services. Louisiana reports a 94% housing retention rate since the program began housing tenants in 2008.
A preliminary analysis shows statistically significant reductions in hospitalizations and emergency department utilization after the PSH intervention, and an early independent analysis of the PSH program’s impact on Medicaid spending found a 24% reduction in Medicaid acute care costs after an individual was housed.
Through a variety of optional and waiver authorities, some states are providing voluntary supported employment services to Medicaid enrollees. Supported employment services may include pre-employment services (e.g., employment assessment, assistance with identifying and obtaining employment, and/or working with an employer on job customization) also as employment sustaining services (e.g., job coaching and/or consultation with employers).
States often target these services to specific Medicaid populations, like persons with serious mental disease or substance use disorders and individuals with intellectual or developmental disabilities. For instance, under a neighborhood 1115 waiver, Hawaii offers supportive employment services to Medicaid enrollees with serious mental disease (SMI), individuals with serious and protracted mental disease (SPMI), and individuals who require support for emotional and behavioral development (SEBD).
Medicaid Managed Care Organizations (MCOs)
Medicaid MCOs are increasingly engaging in activities to deal with social determinants of health. Data from the Kaiser Family Foundation’s 50-state Medicaid budget survey show that a growing number of states are requiring Medicaid MCOs to deal with social determinants of health as a part of their contractual agreements (Box 1). In 2017, 19 states required Medicaid MCOs to screen beneficiaries for social needs and/or provide enrollees with referrals to social services and 6 states required MCOs to supply care coordination services to enrollees moving out of incarceration, with additional states getting to implement such requirements in 2018.40 Other data from a 2017 Kaiser Family Foundation survey of Medicaid managed care plans show that nearly all responding MCOs41 (91%) reported activities to deal with social determinants of health, with housing and nutrition/food security because the top areas of focus.42 the foremost common activities plans reported engaging in were working with community -based organizations to link members to social services (93%), assessing members’ social needs (91%), and maintaining community or welfare work resource databases (81%) Some plans also reported using community doctors (67%), using interdisciplinary community care teams (66%), offering application assistance and counseling referrals for social services (52%), and assisting justice-involved individuals with community reintegration (20%).
samples of States Integrating Social Determinants into Medicaid Managed Care Contracts
Arizona requires coordination of community resources like housing and utility assistance under its managed long-term services and supports (MLTSS) contract. The state provides state-only funding in conjunction with its managed behavioral health contract to supply housing assistance. The state also encourages health plans to coordinate with the Veterans’ Administration and other programs to satisfy members’ social support needs.
The District of Columbia encourages MCOs to refer beneficiaries with three or more chronic conditions to the “My Health GPS” Health Home program for care coordination and case management services, including a biopsychosocial needs assessment and referral to community and social support services.
Louisiana requires its plans to screen for problem gaming and tobacco use and requires referrals to Special Supplemental Nutrition Program for ladies, Infants, and Youngsters (WIC) and therefore the Louisiana Permanent Supportive Housing program when appropriate.
Nebraska requires MCOs to possess staff trained on social determinants of health and be conversant in community resources; plans also are required to possess policies to deal with members with multiple biopsychosocial needs.
Under the ACA, not-for-profit hospitals are required to conduct a community health needs assessment (CHNA) once every three years and develop strategies to satisfy needs identified by the CHNA.
The CDC defines a community health assessment as “the process of community engagement; collection, analysis, and interpretation of knowledge on health outcomes and health determinants; identification of health disparities; and identification of resources which will be wont to address priority needs.” Under the ACA, the assessment must take into consideration input from people that represent the broad interests of the community being served, including those with public health knowledge or expertise.
Some providers have adopted screening tools within their practices to spot health-related social needs of patients. for instance, consistent with a survey of nearly 300 hospitals and health systems conducted by the Deloitte Center for Health Solutions in 2017, nearly 9 in 10 (88%) hospitals screen patients to measure their health-related social needs, though only 62% report screening target populations during a systematic or consistent way.45 These hospitals are mostly screening inpatient and high-utilizer populations.
The National Association for Community Health Centers, in coordination with several other organizations, developed the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PREPARE) tool to assist health centers and other providers collect data to raised understand and act on their patients’ social determinants of health. and most of Other organizations and entities have created screening tools, including Health Leads, a non-profit organization funded by the Robert Wood Johnson Foundation, which has developed a social needs screening toolkit for the providers and CMMI, which released an Accountable Health Communities screening tool to assist providers to identify unmet patient needs.
The ACA provided a key opportunity to assist improve access to worry and reduce longstanding disparities faced by historically underserved populations through both its coverage expansions and provisions to assist bridge health care and community health.
To date, many Americans have gained coverage through the coverage expansions, but coverage alone isn’t enough to enhance health outcomes and achieve health equity. With growing recognition of the importance of social factors to health outcomes, an increasing number of initiatives have emerged to deal with social determinants of health by bringing a greater specialize in health within non-health sectors and increasingly recognizing and addressing health-related social needs through the health care system.
Within the health care system, a broad range of initiatives is launched at the federal and state level, including efforts within Medicaid. Many of those initiatives reflect new funding and demonstration authorities provided through the ACA to deal with social determinants of health and further health equity.
They also reflect a broader system movement toward care integration and “whole-person” delivery models, which aim to deal with patients’ physical, mental, and social needs, also as a shift towards payments tied to value, quality, and/or outcomes.
Although there has been significant progress in recognizing and addressing social determinants of health, many challenges remain. Notably, these efforts require working across siloed sectors with separate funding streams, where investments in one sector may accrue savings in another.
Moreover, communities might not always have sufficient service capacity or supply to satisfy identified needs. Further, there remain gaps and inconsistencies in data on social determinants of health that limit the power to aggregate data across settings or to use data to tell policy and operations, guide quality improvement, or evaluate interventions. Within Medicaid, the growing specialization in social determinants of health raises new questions on the acceptable role Medicaid should play in addressing non-medical determinants of health and the way to incentivize and have interaction Medicaid MCOs in addressing social determinants of health.
The Trump Administration is pursuing policies that will limit individuals’ access to assistance programs to deal with health and other needs and reduce resources to deal with social determinants of health.
The Administration has begun phasing out DSRIP programs,50 is revising Medicaid managed care regulations, and has signaled reductions in funding for prevention and public health. it’s also announced plans to vary the direction of models under the CMMI.
The Administration is also pursuing approaches to enforce and expand work requirements publicly programs, including Medicaid. CMS asserts that this policy is meant to “improve Medicaid enrollee health and well-being through incentivizing work and community engagement” which state efforts to form participation in work or other community engagement a requirement for Medicaid coverage may “help individuals and families rise out of poverty and attain independence.” In guidance, CMS has specified that states implementing such programs are going to be required to explain strategies to help enrollees in meeting work requirements (e.g., linking individuals to job training, childcare assistance, transportation, and other work supports), but that states might not use federal funds for supportive services to assist people overcome barriers to figure.
Data show that the majority of nonelderly Medicaid adults already are working or face significant barriers to figure, leaving a little share of adults to whom these policies are directed. However, eligible individuals could lose Medicaid coverage thanks to difficulty navigating documentation and administrative processes related to these requirements.