Health is foundational for personal and community well-being for all people in America. Yet, the nation struggles to achieve health compared to our international peers and now, compared to even to prior United States health statistics.
Though measures show that quality of care has improved in the past few years, evidence indicates that population health outcomes in the U.S., like infant mortality and life expectancy, have declined. This is despite record spending on the healthcare sector.
Recently, the health care system—largely driven by the shift toward value-based care—is considering how interventions to impact social and environmental circumstances can improve health and decrease the need for costly care and procedures. These interventions are targeted at social determinants of health (SDOH), which include a broad array of domains that affect health and well-being. Examples include access to healthy and affordable food, transportation, housing, incarceration and recidivism, employment and wages, safety, education and other community-based and environmental conditions.
Though any person has the potential to be impacted by social determinants of health, the evidence demonstrates that the impact is most striking for vulnerable populations within the US. This movement away from a singular view of health as an output of medical care toward a holistic view of health as an outcome of clinical care, health behaviors, and the social, economic, and environmental conditions in which we live, work, learn, and play presents an exciting opportunity to improve the public’s health and well-being and drive down costs.
Multiple sectors are intervening to address SDOH and the healthcare sector is particularly active as it seeks to improve the value of services delivered. If designed well, these efforts will promote the health and well-being of individuals and communities, making a more “upstream” impact. But, determining the impact of these initiatives is difficult because the interaction between social determinants and health status is complex.
Evidence indicates that improvements in social determinants are linked to improved health outcomes, but there is less robust evidence demonstrating the impact of SDOH interventions. Adding to the impact assessment challenge is the fact that individuals and communities may experience multiple SDOH factors at once. The causal relationship between any intervention and a specific health outcome becomes difficult to parse in such a case.
To understand the most effective interventions and establish best practices for addressing SDOH, we must develop and agree to a common measurement approach. There has been an increasing amount of activity around measurement of SDOH interventions at the local and national level, but almost none of these efforts are coordinated. Without a shared set of principles to prospectively guide measurement of SDOH and the impact of efforts to address social needs, the field may face familiar pitfalls to those faced in the assessment of health care quality and safety and community health. Examples include an over-abundance of measures or a lack of comparable data.
Prospectively aligning the national approach to measuring interventions now will accelerate our understanding of opportunities to improve the health and well-being of people and communities. It will also help us avoid the challenge of needing to retrospectively align measures, as is the objective of the significant undertaking recently required by Executive Order 13877 directing the Department of Health and Human Services to align measures used in federal programs.
Opportunity for harmonized approach to measurement
Multi-sector and cross-discipline investment and collaboration is needed to design and implement sustainable individual- and community-level SDOH interventions and importantly, to assess their effectiveness. Sustaining these efforts and demonstrating the value of SDOH investment requires us to understand which social risk factors impact health outcomes, and which interventions mediate those relationships.
This demonstrates a clear need for a measurement framework, the selection of key domains, and the identification of core measures to assess SDOH interventions. Consistency and harmonization of measurement enables comparisons across settings, promotes the development and scaling of best practices, creates a supportive environment for identifying sustainable financing models, and produces compelling evidence to support the business case for addressing SDOH.
To understand the most effective interventions and establish best practices for addressing SDOH, the nation should develop and agree to a common measurement approach. Working prospectively and collaboratively to align measurement efforts now will promote investment in, and spreading and scaling of, successful efforts to address social determinants. It would also have the most proximate and significant impact on well-being.
Principles for measuring the impact of SDOH interventions
A set of shared Measurement Principles should guide the development of an SDOH measurement framework, the selection of key domains, the identification of core measures that are applicable across sectors and efforts, and the establishment of performance targets is critical. The following principles provide a foundation for alignment across sectors and efforts:
- The SDOH field should prospectively align on a core set measures, harmonized across sectors to catalyze shared accountability for success.
- Collection of data to inform SDOH measures should, whenever possible, draw from existing data sources to minimize additional burden to all involved sectors, individuals and the community.
- To encourage shared accountability and collaboration, measuring the impact of SDOH interventions should balance the goals and interests of all involved sectors including business, public health, social and human services, medicine, the individual and the community.
- Measurement frameworks that are developed should be created in partnership with the community and reflect the perspectives and aspirations of the individual and of the community.
- Measures should allow multiple sectors to assess progress through leading and lagging indicators in health and well-being.
- Identification of social risk and need should allow efforts to strategically identify people and communities with the greatest need, risk and/or potential for improvement, not only support risk adjustment.
Call to action
If adopted, these principles can guide shared action and ensure that the public and private sector work collaboratively to prospectively align around a shared measurement framework and eventually, a set of core measures.
This should include not only the organizations that are already actively engaged in developing measures, but also the health care sector—including payers and providers, policymakers at all levels of government, the social, human services, and public health sectors, and, importantly, by organizations representing consumers and communities.
The nation is at a critical juncture in understanding the value of social determinants interventions. Prospectively aligning measures for SDOH interventions will enable comparisons across demonstrations or programs, reduce the burden of data collection, and provide useful evidence to support a sustainable business model for addressing SDOH.
We call on all those engaged in work to address SDOH and/or responsible for developing measures to work in an aligned fashion to reduce burden, complexity and advance a shared understanding of impact.
Karen DeSalvo, M.D., chief health officer at Google, and Mike Leavitt, founder of Leavitt Partners, are the co-conveners of the National Alliance to Impact the Social Determinants of Health.