Beyond Health Care: Social Determinants’ Role in Promoting Health and Health Equity
Artiga, Samantha Follow @SArtiga2 and Elizabeth Hinton on Twitter.
Originally published on May 10, 2018.
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ISSUE BRIEF FINAL NOTES
The conditions under which people are born, grow, live, work, and age are referred to as social determinants of health. This fact sheet provides an overview of social determinants of health and new initiatives to address them. It demonstrates:
Socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and access to health care are all examples of social determinants of health. Addressing social determinants of health is critical for improving health and closing long-standing gaps in health and health care.
A growing number of initiatives are being launched to address social determinants of health both within and outside of the health-care system. Initiatives outside of the health-care system aim to shape policies and practices in non-health sectors to promote health and health equity. There are multi-payer federal and state initiatives, as well as Medicaid-specific initiatives, addressing social needs within the health care system. These include Center for Medicare and Medicaid Innovation models, Medicaid delivery system and payment reform initiatives, and Medicaid options. Managed care plans and providers are also involved in activities aimed at identifying and addressing social needs. In 2017, for example, 19 states required Medicaid managed care plans to screen for and/or refer for social needs, and a recent survey of Medicaid managed care plans found that almost all (91%) responding plans reported social determinants of health activities.
Many challenges remain in addressing social determinants of health, and the Trump Administration’s new directions may limit resources and initiatives devoted to these efforts. The Trump Administration is pursuing a variety of new policies and policy changes, such as enforcing and expanding work requirements for public programs and reducing funding for prevention and public health. These changes may limit people’s access to assistance programs for health and other needs, as well as the resources available to address social determinants of health.
Historically, efforts to improve health in the United States have focused on the health care system as the primary driver of health and health outcomes. However, there is a growing recognition that improving health and achieving health equity will necessitate broader approaches that address social, economic, and environmental health factors. This brief provides an overview of these social determinants of health as well as new initiatives to address them.
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What exactly are the Social Determinants of Health?
The conditions under which people are born, grow, live, work, and age are referred to as social determinants of health.
1 They include socioeconomic status, education, neighborhood and physical environment, employment, social support networks, and health care access (Figure 1).
Figure 1 depicts the social determinants of health.
It is critical to address the social determinants of health in order to improve health and reduce health disparities.
2 Despite the fact that health care is essential, it is a relatively weak health determinant. 3 According to research, a variety of factors influence health outcomes, including underlying genetics, health behaviors, social and environmental factors, and health care. While there is currently no agreement in the research on the magnitude of each of these factors’ relative contributions to health, studies suggest that health behaviors such as smoking, diet, and exercise, as well as social and economic factors, are the primary drivers of health outcomes, and that social and economic factors can shape individuals’ health behaviors. Children born to parents who have not completed high school, for example, are more likely to live in an environment that poses health barriers such as a lack of safety, exposed garbage, and substandard housing. They also have less access to sidewalks, parks or playgrounds, recreation centers, and libraries. 4 Furthermore, evidence suggests that stress has a negative impact on health across the lifespan5 and that environmental factors may have multigenerational consequences. 6 Addressing social determinants of health is critical not only for overall health but also for reducing health disparities, which are frequently rooted in social and economic disadvantages.
Initiatives to Address Health’s Social Determinants
A growing number of initiatives to address social determinants of health are emerging. Some of these initiatives aim to increase the emphasis on health in non-health sectors, whereas others aim to have the health care system address broader social and environmental factors that influence health.
Concentration on Health in Non-Health Sectors
Non-health policies and practices have an impact on health and health equity. The availability and accessibility of public transportation, for example, affects access to employment, affordable healthy foods, health care, and other important health and wellness drivers. Nutrition programs and policies can also promote health by, for example, supporting healthier corner stores in low-income communities,7 farm to school programs8, and community and school gardens, as well as broader efforts to encourage the production and consumption of healthy foods. 9 Early childhood education for children from low-income families and communities of color helps to close achievement gaps, improve low-income students’ health, and promote health equity. 10
The “Health in All Policies” approach integrates health considerations into decision making across sectors and policy areas.
11 A Health in All Policies approach identifies how decisions in various sectors affect health and how improved health can help these various sectors achieve their goals. It brings together diverse partners and stakeholders to promote health, equity, and sustainability while also advancing other goals such as job creation and economic stability, transportation access and mobility, a strong agricultural system, and higher educational attainment. States and municipalities are implementing the Health in All Policies approach through task forces and workgroups that bring leaders from various agencies and the community together to collaborate and prioritize a focus on health and health equity. 12 The Affordable Care Act (ACA) established the National Prevention Council, which brings together senior leadership from 20 federal departments, agencies, and offices to develop the National Prevention Strategy in collaboration with the Prevention Advisory Group, stakeholders, and the public.
Place-based initiatives focus on implementing cross-sector strategies to improve health in underserved neighborhoods or communities. There is a growing understanding of the relationship between neighborhoods and health, with zip code being a better predictor of a person’s health than genetic code. 13 A number of initiatives are focusing on implementing coordinated strategies across multiple sectors in communities with social, economic, and environmental barriers that lead to poor health outcomes and health disparities. The Harlem Children’s Zone (HCZ) project, for example, focuses on children in a 100-block area of Central Harlem that has chronic disease and infant mortality rates that are higher than in many other parts of the city, as well as high rates of poverty and unemployment. Through a variety of family-based, social service, and health programs, HCZ aims to improve the educational, economic, and health outcomes of the community.
Taking Care of Social Determinants in the Health Care System
In addition to the growing trend of incorporating health impact/outcome considerations into non-health policy areas, there are new efforts to address non-medical, social determinants of health within the context of the health care delivery system. These include multi-payer federal and state initiatives, Medicaid initiatives led by states or health plans, and provider-level activities aimed at identifying and addressing their patients’ non-medical, social needs.
INITIATIVES AT THE FEDERAL AND STATE LEVELS
In 2016, the ACA-established Center for Medicare and Medicaid Innovation (CMMI) announced a new “Accountable Health Communities” model aimed at connecting Medicare and Medicaid beneficiaries with community services to address health-related social needs. The model includes funding to test whether systematically identifying and addressing Medicare and Medicaid beneficiaries’ health-related social needs through screening, referral, and community navigation services affects health costs and reduces inpatient and outpatient utilization. In 2017, CMMI awarded 32 grants to organizations for five-year participation in the model. Twelve awardees will provide navigation services to help high-risk beneficiaries access community services, while twenty awardees will encourage partner alignment to ensure that community services are available and responsive to enrollees’ needs. 14
A number of states are involved in multi-payer delivery and payment reforms that include a focus on population health and acknowledge the role of social determinants through the CMMI State Innovation Models Initiative (SIM). SIM is a CMMI initiative that provides states with financial and technical assistance for the development and testing of state-led, multi-payer health care payment and service delivery models with the goal of improving health system performance, increasing quality of care, and lowering costs. To date, the SIM initiative has distributed nearly $950 million in grants to more than half of the states in order to design and/or test innovative payment and delivery models. States must develop a statewide plan to improve population health as part of the second round of SIM grant awards. States that received Round 2 grants are taking a variety of approaches to identifying and prioritizing population health needs, connecting clinical, public health, and community-based resources, and addressing social determinants of health.
All 11 states that received SIM testing grants in Round 2 intend to establish connections between primary care, community-based organizations, and social services.
15 In Ohio, for example, SIM funds are being used to support a comprehensive primary care (CPC) program in which primary care providers connect patients with needed social services and community-based prevention programs. The CPC program had 96 practices participating as of December 2017. Connecticut’s SIM model aims to promote an Advanced Medical Home model that will address a wide range of individuals’ needs, including environmental and socioeconomic factors that influence their long-term health.
A number of states that received Round 2 testing grants are establishing local or regional entities to identify and address population health needs, as well as to connect to community services. Washington State, for example, established nine regional “Accountable Communities of Health” that will bring together local stakeholders from various sectors to determine priorities for and implement regional health improvement projects. 16 Delaware intends to establish ten “Healthy Neighborhoods” throughout the state, focusing on priorities such as healthy lifestyles, maternal and child health, mental health and addiction, and chronic disease prevention and management. 17 Idaho is establishing seven “Regional Health Collaboratives” through the state’s public health districts to assist local primary care practices in transforming to Patient-Centered Medical Homes and to develop formal referral and feedback protocols to connect medical and social service providers. 18
Round 2 testing grant states are also engaged in a variety of other activities centered on population health and social determinants. Among these activities are the use of population health measures to qualify practices as medical homes or determine incentive payments, the inclusion of community health workers in care teams, and the expansion of data collection and analysis infrastructure focused on population health and social determinants of health.19
INITIATIVES FOR MEDICAID
Payment and Delivery System Reform
A number of Medicaid delivery and payment reform initiatives include a focus on connecting health care and social needs. These efforts are often part of the larger multi-payer SIM models mentioned above, and they may be part of Section 1115 Medicaid demonstration waivers. 20 Colorado and Oregon, for example, are implementing Medicaid payment and delivery models that focus on the integration of physical, behavioral, and social services, as well as community engagement and collaboration.
Each Coordinated Care Organization (or “CCO”) in Oregon is required to form a community advisory council and conduct a community health needs assessment.
21 CCOs receive a lump sum payment for each enrollee, allowing CCOs to offer “health-related services” that supplement traditional covered Medicaid benefits and may address social determinants of health.
22 Early findings indicate that CCOs are collaborating with community partners and addressing social factors that influence health through a variety of projects. One CCO, for example, has funded a community health worker to assist in connecting pregnant or parenting teens to health services as well as addressing other needs such as housing, food, and income. 23 Another CCO collaborated with providers and the local Meals on Wheels program to deliver meals to Medicaid enrollees who were recently discharged from the hospital and required food assistance as part of their recovery. 24 CCOs were associated with lower spending growth and improvements in some quality domains, according to a 2017 study conducted by Oregon Health & Science University’s Center for Health Systems Effectiveness. 25 The majority of CCOs believed health-related flexible services were effective at improving outcomes and lowering costs, according to the evaluation. 26
Similarly, in Colorado, Regional Collaborative Organizations (RCCOs), which are paid a per member per month fee for enrollees, help connect individuals to community services through referral systems as well as targeted programs designed to address specific community needs.
27 A 2017 study comparing Oregon’s CCO program to Colorado’s RCCO program discovered that Colorado’s RCCO program resulted in comparable savings in expenditures and inpatient care days. 28
Several other state Medicaid programs have implemented Accountable Care Organization (ACO) models, which frequently include population-based payments or total cost of care formulas and may provide incentives for providers to address the broad needs of Medicaid beneficiaries, including social determinants of health.
Through “Delivery System Reform Incentive Payment” (DSRIP) initiatives, some state Medicaid programs are assisting providers in focusing on social determinants of health. The Obama Administration launched DSRIP initiatives as part of Section 1115 Medicaid demonstration waivers. Medicaid funding for eligible providers is linked to process and performance metrics in DSRIP initiatives, which may include addressing social needs and factors. In New York, for example, provider systems may implement DSRIP projects to ensure that people have supportive housing. Outside of its DSRIP waiver, the state has also invested significantly in housing stock to ensure a better supply of appropriate housing. 30 Some providers in Texas have used DSRIP funds to install refrigerators in homeless shelters to improve people’s access to insulin. 31 The California DSRIP waiver has increased the emphasis on coordination between public hospital systems and social service agencies and county-level welfare offices. 32 To date, data on the outcomes of DSRIP programs are scarce, but a final federal evaluation report is expected in 2019. 33
Through the health homes option established by the ACA, Medicaid programs are also providing broader services to support health. States can use this option to establish health homes to coordinate care for people with chronic conditions. Comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referrals to community and social support services are all part of health home services. A designated provider, a team of health professionals linked to a designated provider, or a community health team can all be health home providers. In fiscal year 2017, 21 states reported having health homes in place. 34 According to a federally funded evaluation of the health homes model, most providers reported significant growth in their ability to connect patients to nonclinical social services and supports under the model, but lack of stable housing and transportation were common problems for many enrollees that providers found difficult to address due to insufficient affordable housing and rent support resources. 35
Housing and Employment Assistance
Some states offer housing assistance to Medicaid enrollees through a variety of optional state plan and waiver authorities. While states cannot use Medicaid funds to pay for room and board, Medicaid funds can be used to support a variety of housing-related activities such as referral, support, and case management services that help connect and retain people in stable housing. 36 For example, the Louisiana Department of Health collaborated with the Louisiana Housing Authority to establish a Permanent Supportive Housing (PSH) program to prevent and reduce homelessness and unnecessary institutionalization among people with disabilities. The Medicaid program in Louisiana covers three phases of tenancy support services for Medicaid beneficiaries in permanent supportive housing: pre-tenancy services (housing search assistance, application assistance, and so on), move-in services, and ongoing tenancy services. 37 Since the program began housing tenants in 2008, Louisiana has reported a 94% housing retention rate. An early independent analysis of the PSH program’s impact on Medicaid spending discovered a 24% reduction in Medicaid acute care costs after a person was housed, according to a preliminary analysis. 38
Some states provide voluntary supported employment services to Medicaid enrollees through a variety of optional and waiver authorities. Pre-employment services (e.g., employment assessment, assistance with identifying and obtaining employment, and/or working with employer on job customization) and employment sustaining services (e.g., job coaching and/or consultation with employers) are examples of supported employment services. States frequently target these services to specific Medicaid populations, such as people suffering from serious mental illness or substance abuse problems, as well as people with intellectual or developmental disabilities. Hawaii, for example, provides supportive employment services to Medicaid enrollees with serious mental illness (SMI), individuals with serious and persistent mental illness (SPMI), and individuals who require support for emotional and behavioral development under a Section 1115 waiver (SEBD). 39
Medicaid Managed Care Organizations (MCOs) Medicaid MCOs are increasingly addressing social determinants of health. According to data from the Kaiser Family Foundation’s 50-state Medicaid budget survey, an increasing number of states are requiring Medicaid managed care organizations (MCOs) to address social determinants of health as part of their contractual agreements (Box 1). In 2017, 19 states required Medicaid managed care organizations (MCOs) to screen beneficiaries for social needs and/or refer enrollees to social services, and six states required MCOs to provide care coordination services to enrollees transitioning out of incarceration, with more states planning 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 social determinants of health activities, with housing and nutrition/food security being the top areas of focus. 42 Working with community-based organizations to connect members to social services (93%), assessing members’ social needs (91%), and maintaining community or social service resource databases (81%) were the most common activities reported by plans (Figure 2). 43 Some plans also reported the use of community health workers (67%), interdisciplinary community care teams (66%), application assistance and counseling referrals for social services (52%), and assistance with community reintegration for justice-involved individuals (20%).
Step 1 In your initial post, respond to the following prompts.
Describe a client using certain characteristics such as age, social supports, and type of community.
Describe the social determinants to health promotion for a specific client in your community with whom you are familiar.
Describe the role of social support in health promotion for this client.
Describe the relationship between social support and social determinants in accessing health promotion for this client.
Cite any sources in APA format.