Top Effective Social Determinants of Health Interventions

March 09, 2022 - The types of social determinants of health that medical providers may identify in their patients vary, meaning it will take numerous social determinants of health interventions to support patient wellness.

But with these hospital- or clinic-based social service referrals being somewhat in their nascency, not every organization has a solution for every social determinant of health. For one thing, the medical industry is still building an evidence base for these social services, so organizations don’t always know for sure which interventions will improve outcomes and potentially have some return on investment.

Additionally, healthcare organizations might not have resources or community partners that can address some social determinants of health—at least not yet. Said otherwise, hospitals and clinics might be able to refer a patient to affordable housing, but they don’t know how to solve neighborhood violence.

As a result, several top effective social determinants of health interventions have come to light. Although they are new, many healthcare organizations have built out some SDOH programming that includes screening and referral.

Where that referral goes is not the same at every provider. Some organizations may have more community health partnerships than others, or more capabilities to connect patients to social services.

However, interventions focused on food insecurity, housing insecurity, and transportation have come to the forefront as common SDOH programs, according to the National Committee for Quality Assurance (NCQA), which recently pitched some measures for SDOH screening and programming.

“Food, housing, and transportation—that certainly isn’t the full portfolio of social needs,” Rachel Harrington, PhD, a research scientist at NCQA, said in an interview. “We know there are others that are critically important as well, such as economic security, or interpersonal violence typically comes up as well.”

Harrington said there’s already a lot of infrastructure, including data standards, for those particular determinants. Through qualitative stakeholder engagement, NCQA also observed these determinants as ones organizations could immediately act upon.

Below, PatientEngagementHIT outlines food insecurity, housing insecurity, and transportation and how organizations may begin addressing them.

Social determinants of health screening

Effective social determinants of health programs need to begin with screening so providers and community leaders can personalize interventions to individual patient needs. In 2020, researchers wrote in the American Journal of Managed Care that SDOH screening is essential and that organizations should develop a questionnaire that is tailored to their populations.

“Codesigning screening tools with patients, clinicians, and community stakeholders is a useful strategy; patients can provide valuable insights into the most important questions to ask, clinicians can ensure that screening processes dovetail with their clinical work, and representatives of community-based organizations are privy to the needs and preferences of the communities they serve,” the researchers wrote.

Some healthcare organizations use paper and pen for this screening and then manual data entry into the EHR, but this process can be arduous. Recently, health IT for collecting and integrating SDOH data have come to market.

At Nemours Children’s Health, digital SDOH screening has made it easier for pediatricians to address the social factors affecting the health and wellness of children and families. Importantly, the organization has specific questions that fit the social services with which Nemours has partnerships.

Additionally, Nemours providers prioritize building patient trust while conducting the screening to make patients feel comfortable disclosing more personal information.

“We've been offering this screening tool in advance of the visit, so people can feel comfortable in their homes or in work settings to answer the questions, or they can even do it through the Nemours computer-based system,” Kara Odom Walker, MD, MPH, MSHS, chief population health officer at Nemours, said in a phone interview.

“But more important than words are often the people,” she continued. “It's knowing the nurse, or the social worker, or the pediatrician, or the clinical provider in that environment that builds trust.”

Providers may also consider outlining the importance of SDOH, informing the patient the organization has resources should a need pop up, and giving patients space if patients do not wish to complete all of part of the screening.

Addressing food insecurity

Healthcare organizations largely address food security through community health partnerships with healthy food providers, like food pantries.

A July 2020 program out of CDPHP and Healthy Alliance Individual Practice Association (Healthy Alliance IPA) helped CDPHP, a Medicaid provider, offer food access for some Medicaid members. The payer and its provider partners were in charge of identifying patients who would benefit from the program. Healthy Alliance IPA and The Food Pantries for the Capital District operated the program.

Members could be enrolled in one of four food access plans, some of which offer medically tailored food and meal delivery for those also experiencing transportation challenges.

This program hinges on community health partnership and careful SDOH screening.

Some may also refer patients to benefits like SNAP, leveraging community health workers to help patients register for the benefit. However, some studies have shown that the SNAP benefits are insufficient to fully address the scope of food insecurity.

Finally, some healthcare organizations have begun to build their own food pantries. At Boston Medical Center, a rooftop vegetable garden helps providers guide their patients in healthy eating and helps fill the organization’s own food pantry.

“We have a preventative food pantry that’s been in place here at Boston Medical Center for 14 years. It’s run by a gentleman by the name of Latchman Hiralall. He’s a diet technician,” David Maffeo, the senior director of Support Services at Boston Medical Center, said on the organization’s podcast.

“The way it works is patients have to be prescribed to the food pantry by their practitioner,” Maffeo added. “They come to the food pantry once or twice per week based on their needs. My team on sight supplies them with a healthy mixture of foods – a lot of produce, a lot of vegetables.”

BMC also has a demonstration kitchen, where staff can show patients how to create nutritious meals.

These programs yield a good return on investment, with researchers writing in 2019 that food security programs are a “best buy” investment.

Providing safe, stable housing

Many healthcare organizations across the country have prioritized SDOH programs that focus on housing insecurity through two main paths: funding affordable housing complexes and referring patients to housing assistance.

Typically, large organizations with a lot of capital invest in building affordable housing complexes. In February 2022, CVS Health announced a slate of affordable housing grants to build transitional housing. For example, in the round of funding dedicated to Nashville, CVS Health said the housing unit would be built in a neighborhood traditionally home to Black people.

These housing units often have other SDOH-related services, like job training and placement and other wellness features.

But healthcare organizations without the capital to invest in housing units can still address housing insecurity. Through community heath partnerships, organizations can refer patients to social services that would help place them in transitional or affordable housing.

A housing security program, Health Starts at Home, run by The Boston Foundation, showed that a housing security intervention helped reduce housing insecurity among kids and improved health outcomes.

Kids who worked with one of four community partners focused on housing placement had good self-reported health a year after placement. Caregivers also reported better mental health and housing conditions.

Each of the four community partners used different strategies to recruit families for the program. Some focused on individuals who frequently visited the emergency department, while others used traditional SDOH screening tools to identify those reporting housing insecurity.

Rideshare, NEMT support transportation needs

Rideshare and other transportation services have become a mainstay in the healthcare space because they pose a cost-effective solution to get patients to the care they need.

In a widely cited 2016 American Hospital Association report, researchers reported that 3.6 million individuals do not access healthcare because they don’t have a ride to their appointments. Four percent of all children miss a medical appointment because they don’t have a ride.

This can have negative health consequences, especially for developing kids, people recovering from an acute episode, or individuals with a chronic illness that needs regular checks.

Healthcare organizations have long relied on non-emergency medical transportation companies to provide transport to some populations. In fact, this is a covered benefit under Medicaid plans. NEMT has proven highly effective at connecting people to rides, and some companies have even dipped their toes in connecting people to other social services.

But as healthcare has come to appreciate the enormity of transportation needs, many have tapped rideshare companies like Uber and Lyft to fill in the gaps. These companies can facilitate low-cost rides for completely ambulatory patients who do not need any medical care during the ride. For example, rideshare would be a good fit for patients with diabetes going in for an A1C check and who have no other medical needs.

For patients with medical equipment, like a wheelchair, or who otherwise need specialized attention, NEMT proves to be the best partner. That distinction underscores the importance of SDOH screening and tailored SDOH intervention.

As noted above, rideshare and NEMT providers alike are starting to help patients get other places besides medical appointments. Uber and Lyft both offered rides to COVID-19 testing and vaccination sites, while some NEMT companies repurposed to deliver food or help people get to other social services.