3 Ways Healthcare Organizations Can Advance Health Equity by Addressing Social Determinants of Health

Ben Tuck
March 1, 2022

This post is part of our health equity series. Please read our overview post, Why Health Equity Matters in 2022, to learn more about how you can help advance health equity.

Social determinants of health (SDoH) profoundly affect a person’s overall health, and according to the Centers for Disease Control and Prevention (CDC), addressing them is one of the “primary approaches to achieving health equity.” SDoH, defined as “the non-medical factors that influence health,” encompass the conditions in which people are born, grow, work, live, and age, including:

  • Individual and household income
  • Early childhood development 
  • Level and quality of education
  • Access to nutritious food
  • Access to health services of sufficient quality
  • Living conditions and housing status
  • Level of social inclusion and access to social services
The five social determinants of health categories


These factors are rooted in socioeconomic status, greatly impact health outcomes, and directly contribute to persistent health inequities. The World Health Organization (WHO) estimates that SDoH account for up to 30–55% of health outcomes globally and contribute more to overall population health than medical care or genetics. While there is no consensus on the exact impact of SDoH outcomes within the U.S., there is an extensive body of evidence indicating their overwhelming importance. One study concluded that “potentially avoidable factors associated with lower educational status account for almost half of all deaths among working-age adults in the U.S.”


Socioeconomic factors are also closely linked to the development of health-related behaviors that affect outcomes. For example, children exposed to smoking and substance abuse in their communities are more likely to adopt these practices later in life. Similarly, fewer opportunities to exercise and eat well as a child can lead to developing behaviors and habits that may increase risk for chronic diseases.


Addressing SDoH is an economic imperative. Health disparities cost hundreds of billions of dollars annually in direct medical costs and indirect costs tied to lost productivity. This is especially concerning, as national health spending is projected to reach $6.2 trillion by 2028, but 25% of total healthcare spending is estimated to be wasted. Given the estimated impact of SDoH relative to medical care, proactively addressing the socioeconomic factors propagating health disparities may significantly reduce this excess spending while improving outcomes.


An Example of SDoH: Where You Live Matters

The definition of SDoH is broad and examining a single subset of social factors can help contextualize how significantly they contribute to health outcomes and propagate health disparities. Consider just the environment in which people live. A person’s ZIP code is a stronger predictor of their overall health than other factors, and in some U.S. cities, a child’s life expectancy can vary more than 25 years between neighborhoods that are only a few miles apart. Where someone lives is associated with a variety of social factors that can negatively affect health, and may include: 

Living space determines proximity to grocery stores and other sources of healthy foods, as well as the availability of reliable transportation required to reach these locations. This phenomenon, known as a food desert, may deprive people of access to affordable food options and leave them with insufficient nutrition, ultimately leading to higher rates of chronic conditions and adverse health outcomes. Research estimates that food deserts affect 19 million people in the U.S. (6.2% of the population) and disproportionately affect Black, multiracial, and low-income communities.

Living in communities with higher crime rates and violent incidents is associated with worse health outcomes. Even if an individual does not personally experience such events, they can still suffer indirect consequences. According to the Department of Health and Human Services, “children exposed to violence may experience behavioral problems, depression, anxiety, and post-traumatic stress disorder.” 

According to the WHO, one third of all deaths from stroke, lung cancer and heart disease are due to air pollution. The WHO also notes the impact on children, stating that “worldwide, up to 14% of children aged 5-18 years have asthma relating to factors including air pollution.” Water pollution is just as impactful. Recently, the Flint water crisis led to 12 deaths and left tens of thousands of people to subsist on lead-contaminated drinking water. Unfortunately, the impact of environmental factors will only continue to increase as climate change accelerates.

Living spaces that don’t support regular exercise can also significantly contribute to worse health (e.g., greater rates of obesity and diabetes). Neighborhoods may suffer from a lack of safely walkable areas, a dearth of public transportation options, and limited or no recreational spaces, such as public parks, pools, and fields. Further, high levels of crime and violence may prevent residents from exercising in public spaces. 


The significance of living conditions extends far beyond the examples listed above. Due to their place of residence, people may also lack access to broadband internet, health services, educational opportunities, and may be exposed to frequent tobacco use and substance abuse.

How Healthcare Organizations Can Address SDoH 

Addressing SDoH is critical to achieving health equity and succeeding in value-based care. To this end, healthcare organizations (HCOs) can participate in CMS’s alternative payment models (APMs), which incentivize tackling the root causes of poor health and provide reimbursement for quality of care rather than quantity of services provided. Further, HCOs can collaborate with community-based organizations that systematically link healthcare and social services for people at risk of poor outcomes. Increasingly, these collaborations are forming to specifically address SDoH, and partnerships between clinicians, social service agencies, and health systems are on the rise.

Collaborate With Community-Based Organizations

One such collaboration is the Pathways Community HUB care management model (HUB). Originating in Toledo, Ohio, the HUB is a value-based approach to care coordination that specifically addresses SDoH by connecting at-risk individuals with local healthcare organizations and community health workers. Payment is predicated on risk mitigation and achieving specific outcomes; for example, meeting a six-month sobriety goal for a person that previously struggled with alcohol or ensuring a previously unemployed person has been hired and remains employed for several months. 


The HUB care model targets individual, modifiable risk factors (e.g., lack of housing), and uses a technical tool called a “Pathway” that serves as a comprehensive checklist to address each factor. Pathways help to outline step-by-step improvements and ultimately lead to completing a specific outcome goal. While Pathways help to ensure meaningful progress, each individual Pathway is also considered in tandem with all of a person’s other risk factors. For example, “An expectant teenage mother at risk for a low-birthweight, preterm delivery who is simultaneously homeless, depressed, and without access to medical care must have all three factors addressed, since fixing one by itself is unlikely to make much difference in the outcome.” 


Rather than creating Pathways for each issue and attempting to resolve them all at once, health workers identify the person’s most pressing need and address it first. Using Pathways, they work with people to make steady progress on their most urgent issues and eventually work towards less critical factors over time. Even if some Pathways aren’t fully completed through this approach, the data they produce is still valuable to HUB. Information on unfinished Pathways may demonstrate a need for greater investment in community infrastructure and help local HCOs identify specific social factors creating health disparities in their population. 


Pathways Community HUB has received funding and support from the Agency for Healthcare Research and Quality (AHRQ), has established a national certification program, and continues to grow. Today the HUB model is helping to close health disparities for nearly 8,000 people monthly with approximately 400 certified health workers. 


The Idaho Health Data Exchange (IHDE) is another example of HCO collaboration designed to address SDoH. A statewide data exchange that enables HCOs to coordinate care, the organization recently partnered with Aunt Bertha, a search and referral platform for social services, to educate its users on SDoH and bridge the gap between clinical environments and their local communities. Now, they’re enabling providers and payers to connect with community-based organizations across the state, improving quality of care and directly impacting social factors.

Three Steps to Get Started

1. Collect Data and Identify Specific Needs

Identifying specific social needs by collecting non-medical, demographic data is the first step towards launching a SDoH initiative or beginning a partnership with community-based organizations. Collecting SDoH data is key to pinpointing the most actionable areas for improvement and the population subsets at the highest risk for negative outcomes due to specific SDoH factors. To conduct this analysis, HCOs can distribute social needs assessment surveys, organize meetings with local leaders and social services organizations, and draw on publicly available datasets, such as the Area Deprivation Index


To aid in this process, AHRQ has created a repository of tools designed to help HCOs assess social risks and needs. Their resources include:

  • Screening tools and surveys that evaluate SDoH needs
  • SDoH data collection, summary, and referral tools
  • Tools to help organizations form clinical-community linkages
  • Care coordination resources and tools for delivering culturally competent care
  • Literature about federal data sources that can be used to measure SDoH

Collecting SDoH data and survey responses regularly is critical; social circumstances change over time and the issues people face may not be reported in clinical encounters. Surveys and other outreach methods that inquire about SDoH can help to foster discussion and encourage people to share their needs. 

2. Research Local Community-Based Organizations

Once enough data has been collected to determine which modifiable social factors are having the greatest negative impact, HCOs will be able to take the next step—identifying and researching community-based resources that map to these factors. Several resources exist to help HCOs familiarize themselves with local community resources and discover organizations they may be unaware of:

  • The American Academy of Family Physicians Neighborhood Navigator is a regularly updated database of community-resources organized by ZIP code. Neighborhood Navigator also includes tools to manage referrals and shareable literature that explains how individuals can use and benefit from specific CBO services. 
  • The National Association of County and City Health Officials provides HCOs with a directory of U.S. health departments that are categorized at the county and city level. Local health departments generally have long standing relationships with CBOs in the same area and can help connect HCOs to the most appropriate organizations. 
  • Aunt Bertha’s search and referral platform for social services enables HCOs to identify and contact a myriad of local organizations dedicated to addressing SDoH. 

3. Form Partnerships and Set Measurable Goals

When engaging with CBOs that share a commitment to addressing a specific SDoH, HCOs should come to the table with an understanding of their available resources and how they can most effectively drive productive collaboration. Generally, HCO involvement will center on referring people to services offered by the CBO and supporting the CBO’s existing efforts. However, these actions require internal support and communication. HCOs should:

  • Disseminate key information about the collaboration and ensure employees are well informed about the services offered. They must be able to clearly communicate the benefits to patients or members and easily navigate the referral process.
  • Establish an easy-to-use communication channel that enables employees to inform CBO workers when they refer someone. 
  • Set appropriate expectations regarding the partnership’s scope and the expected results. Addressing SDoH is a complex process that hinges on factors beyond a traditional clinical setting, and HCOs should determine realistic goals that account for both organizations’ resource availability and staffing capacity.
  • Develop key outcomes or metrics of progress to track performance, assess impact, and use this information to improve programs whenever possible. This data can be further augmented with stakeholder feedback and qualitative assessments that evaluate how specific processes, such as outreach messaging, could be improved and what has been most effective. 

The Center for Health Care Strategies has also compiled a repository of resources to help organizations streamline collaborations that address SDoH, including a partnership assessment tool. This tool is designed to help partners “understand progress toward benchmarks characteristic of effective partnerships, identify areas for further development, and guide strategic conversations.” 

Addressing SDoH With Technology

Driving new and existing initiatives with SDoH data and using this data to design and collaborate on interventions will help close health equity gaps. HCOs can also go a step further by implementing technology solutions to coordinate care, predict risk tied to SDoH on an individual level, and surface the specific SDoH factors that contribute most significantly to increased risk. In particular, AI solutions can help organizations use limited care management resources and target SDoH interventions with greater efficiency. 


For example, Genesis Physicians Group, the largest network of independent primary and specialty care physicians in North Texas, is using ClosedLoop to build predictive AI models that help the network mitigate SDoH contributors to health risk


To learn more about how Genesis Physicians Group and ClosedLoop are using AI to tackle SDoH and advance health equity, please check out this video interview with Dr. Jim Walton, President and CEO of Genesis Physicians Group, and Carol McCall, ClosedLoop's Chief Health Analytics Officer. 


This post is part of our health equity series. If you’re interested in learning more about health equity and what can be done to achieve it, please check out our comprehensive overview post: Why Health Equity Matters in 2022, and our other posts on health equity:

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