Far-reaching interventions needed to address social determinants of health

Meaningful population health management will require deeper, further-reaching interventions to address social determinants of health, according to a new issue brief from the Kaiser Family Foundation.

The United States spends a disproportionate amount on healthcare compared to other industrialized countries, but research shows healthcare only accounts for about 10 percent of risk of premature death, according to the brief, with individual behavior and social/environmental factors making up a combined 60 percent.

A meta-analysis of multiple studies finds up to 1 in 3 annual U.S. deaths can be traced back to factors such as education, employment status, income and racial segregation. Recent public health interventions focus on entire communities, such as a Camden, New Jersey, initiative that created a citywide care management system to bridge gaps between the city's many high utilizers of care and primary care providers. This team puts the patients in touch with providers and social workers to identify their needs, which has cut emergency department and hospital use as well as strengthened patients' connection to primary care post-discharge, according to the report.

Meanwhile, multiple states have developed programs to factor socioeconomic needs into healthcare delivery, according to the brief. For example, the Centers for Medicare & Medicaid Services' State Innovation Models (SIM) Initiative has provided several states with testing grants for plans to tackle social determinants of health. In New York, SIM funds will go to public health consultants who will put patients in touch with local resources that address health determinants. Washington State, meanwhile, has developed a plan to integrate community services into care as well as create local "Accountable Communities of Health," in which providers, health plans, public health agencies and local government collaborate to improve population health.

Community health centers have also historically been successful meeting their patient populations' clinical and non-clinical needs, leading to the recent launch of a new program from the National Association for Community Health Centers, which will develop and test new standardized patient risk assessment best practices for sociodemographic health determinants, according to the brief.

To learn more:
- read the issue brief

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