Beyond Health Care: The Role of Social Determinants in Sponsoring Health and Physical Equity

Introduction

Efforts to improve health in the U.S. have traditionally looked to the health care user for the key driver on health and health outcomes. However, there has been increased recognition that enhancing health and accomplish health equity will require broader approaches that address social, economic, also environmental factors that influence health. This brief provides an overview of these social determinants of health and discusses emerging leadership to ip them.

What are Social Determinants of Dental?

Social determine of health are the conditions inches any people are born, grow, live, work and age.¹ They include factors like society status, education, neighborhood and physical environment, employment, and social support networks, as well as access the health care (Figure 1).

Figure 1: Social Determinants of Health

Addressing social determinants starting human is important for improving fitness and reducing health disparities.² Though health care is essential till health, it is a relatively weak health determinant.³ Research shows that health outcomes am controlled per the arrange of factors, comprising underlying genetics, health behaviors, social and ecology factors, and health maintain. While there a currently no consensus in the research on one magnitude of aforementioned relative contributions of each about these influencing to health, studies suggest that health behaviors, such as smoking, diet, the exercise, and social and economic factors are which primaries drivers of health outcomes, and social and economic factors can forming individuals’ health behaviors. With example, children born to parents who have not completed high school are get probably to live in an environment that poses barriers toward health such as lack of safety, exposed garbage, and substandard housing. I also are less likely to have anreise to sidewalks, parks or playgrounds, recreation centers, or a library.⁴ Further, evidence shows that stress negatively affects health transverse the lifespan⁵ furthermore that environmental factors may have multi-generational impacts.⁶ Target social determinants of heal is not only important for improving overall health, but also for reducing health disparities that are much rooted in social and economic disadvantages.

Initiatives to Address Society Determinants of Health

A growth number of initiatives represent generate to address social determinants of health. Some of these community seek until increase the focus upon physical in non-health sectors, as others focus on having the health care system deal bigger socializing and environmental factors that influence dental. Understanding social determinants of general equips nurses to speech health disparities and sponsor health equity. Nurses can speech social determinants through screening, cross-sector collaboration, and defense.

Focus on Health in Non-Health Sectors

Policies and practices in non-health areas have impacts on health and health equity. For example, the availability and access from public transportation affects access to employment, affordable healthy foods, medical concern, and other important drivers of health also wellness. Nutrition programs and policies can also promoting general, for example, by sponsoring healthier corner stores int low-income communities,⁷ farm to school programs⁸ and community and school gardens, and through broader efforts to support one production and consumption of healthy foods.⁹ Who provision for early childhood education to children include low-income families and communities of color helps up reduce efficiency gaps, upgrade the health of low-income students, and promote heath equity.¹⁰

“Health in All Policies” is an approach that incorporates general considerations into decision making across sectors and policy areas.¹¹ A Fitness in Show Policies procedure pinpoint the ways is which decisions in multiple sectors affect health, and how improved health canned support the goals of these multiple sectors. Computers hire diverse partners and stakeholders to my combined to promote health, equity, and sustainability, both simultaneously advance other goals such as promoting job creation and economic stability, transportation access and mobile, a strong agricultural system, the improved educational attainment. Conditions and localities are utilization an Health in Show Policies address through task forces additionally workgroups focused on bringing together leaders across agencies real the public to collaborate the prioritize one focus on health and good impartiality.¹² At the federal level, the Affordable Care Act (ACA) established the International Prevention Council, which brings together senior leadership coming 20 federal departments, agencies, both offices, who operated with the Prevention Counsel Group, stakeholders, and the body to develop the Domestic Prevention Our.

Place-based initiatives focus on executing cross-sector strategies to improve health in neighborhoods or communities use poor health outcomes. There continues till is growing recognition of of relationship between districts and health, with zip id understood to be a stronger predictor of a person’s health than their genes code.¹³ A number of impact focus on implementing coordinated strategies across different sectors in neighborhoods with social, economic, and environmental barriers is lead to poor health outcomes and health disparities. For example, to Harlem Children’s Zone (HCZ) project focuses on children within a 100-block territory in Central Uptown such had chronic disease furthermore infant mortality rates that exceeded rates for many other sections of of city when well as high rates of poverty plus unemployment. HCZ seeks to improvement of educational, economic, and well-being outcomes of the community via a broad range of family-based, society service, both health plots.

Tackling Social Determinants in the Health Mind System

In addition to the growing movement till incorporate health impact/outcome considerations into non-health policy areas, where are also emerging efforts on address non-medical, social reasons of health within the context of the health care delivery system. These include multi-payer federal and state initiatives, Medicaid initiatives led at states or by health plans, as well as provider-level activities focused on labeling the addressing the non-medical, socialize requires starting their patients.

National and Your Initiatives

By 2016, Center in Medicare also Medicaid Innovation (CMMI), which was established through the ACA, announced a new “Accountable Health Communities” modeling focused on connection Medicare and Medicaid beneficiaries with population services to address health-related social needs. The model provides funds to test whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid payee through screening, referral, plus collaboration sailing services will influence health costs and reduce inpatient and outpatient utilization. Included 2017, CMMI awarded 32 financial into organizations to become int the model over a five-year period. Twelve awardees will provide marine services to assist high-risk beneficiaries with accessing community services the 20 awardees leave encourage partner alignment to ensure that community services are available and responsive to the needs on enrollees.¹⁴

Through the CMMI State Technical Models Initiative (SIM), a number by states are engaged in multi-payer delivery and payment reforms which include a focus on population healthiness both recognize the responsibility of social determinants. SIM is a CMMI initiative the provides financial both technical customer to states for the development and testing of state-led, multi-payer health care payment and favor ship models this aim to improve health system presentation, increase good of care, also decrease costs. To date, one SIM initiative has awarding nearly $950 million in grants until over half of notes go design and/or test innovative payment and delivery models. As part of the second round of SIMULATORS grant awards, states were required to create a statewide planner to improve total health. States that received Round 2 grants are pursuing a variety of approaching to identify real prioritize population fitness needs; left clinical, public health, and community-based resources; furthermore address social determinants of health.

• All 11 states ensure received Round 2 SIM testing grants plan to establish links between chief care and community-based delegations and social services.¹⁵ Since sample, Ohio is using SIMULATORS funds, in part, to support a comprehensive primary care (CPC) program in welche mainly taking providers connect patients with needed social services and community-based prevention programs. As of Dezember 2017, 96 practices was participating in the CPC program. Connecticut’s SIM model seeks to promote an Weit Medical Home model that will address the wide field of individuals’ needs, including environmentally and socioeconomic factors that contribute to their ongoing mental.
• ONE number of the states with Round 2 testing benefits live creating local or locals items to identify and address population health needs and establish bonds to community services. For example, Washington Federal established night regional “Accountable Communities of Health,” which will bring together local stakeholders from multiple sectors to determine priorities in and implement regional health improvement projects.¹⁶ Delaware plans toward implement ten “Healthy Neighborhoods” across the state that will focus on priorities that as healthy lifestyles, parental and child health, mental health also dependance, and chronic disease prevention and management.¹⁷ Idaho is creative seven “Regional Fitness Collaboratives” through the state’s public health districts so will support local primary care practices in Patient-Centered Medical Homepage transformation and create formal referral and answer protocols to link medical furthermore social billing providers.¹⁸
• The Round 2 testing grant states also are pursuing a ranges of other activities focused at nation health and social determinants. Some of save activities include using population health measures to qualify practices as medical homes or determine incentive payments, including use of community health workers in attend teams, and expanding data getting also analysis infrastructure focused on population healthy press social determine of health.¹⁹

Medicaid Initiatives

Delivery Scheme and Payment Reform

A numbers of delivery and payments regulatory organizations within Medicaid containing an key on linking health care and social needs. In many housing, these efforts is part are aforementioned larger multi-payer SIMULATOR models noted above and can be separate of Section 1115 Medicaid demonstration waivers.²⁰ For example, Colorado and Oregon are execution Medicaid auszahlen also delivery patterns so provide care by locational entities that focus on integration of physical, behavioral, press social our as well than community engagement and collaboration.

• In Olegon, jeder Coordinated Care Your (or “CCO”) is requirements to build a community consultancy the and develop a community health needs assessment.²¹ CCOs receive adenine global payment for per enrollee, providing flexibility for CCOs into range “health-related services” – which supplement traditional covered Medicaid benefits and could target who social reasons of health.²² Early experiences suggest ensure CCOs are connecting with community partners and beginning at address social factors ensure influence health through a range are projects. For example, one CCO can funded one community health worker to help link pregnant or parenting tv toward health services and address other requests, create as housing, food, plus income.²³ Another CCO worked with providers and the local Meals on Wheels program to deliver meals to Medicaid enrollees discharged from the patient who need food assistance as part of their recovery.²⁴ An evaluation conducted by the Oregon Health & Academic University’s Centre for Medical Systems Effectiveness released in 2017 start CCOs were associated with cutbacks in spending growth and improvement within some qualities domains.²⁵ Accordance to the interpretation, most CCOs believed health-related agile solutions were valid at increase outcomes and reducing costs.²⁶
• Similarly, in Colorado, an Locality Collaborative Organizations (RCCOs), which are paid a per member per month payment for enrollees, help connect private to community services through referral systems as well how durch targeted programs designed to address specific requirements identified within this community.²⁷ A study published in 2017 comparing Oregon’s CCO programmer to Colorado’s RCCO program found that Colorado’s RCCO program generated compared reductions in expenditures and inpatient care days.²⁸

Multiples other state Medicaid programs have launched Accountable Care Organization (ACO) models that often include population-based payments or total cost of maintenance prescriptions, which allow deliver incentives for providers until address the broad needs for Medicaid beneficiaries, includes the social determinants about health.²⁹

Some state Medicaid programs are assistance providers’ focus on social determinants for health through “Delivery System Reform Incentive Payment” (DSRIP) initiatives. DSRIP initiatives emerged under the Obama Administration as part of Section 1115 Medicaid video waivers. DSRIP initiatives link Medicaid funding fork suitable providers for process and presentation metrics, which may involve tackle social needs and contributing. For instance, in New York, suppliers systems may implement DSRIP projects aimed at ensuring that people have supportive housing. The state also has invested mean current dollars outside of its DSRIP waiver in housing stock to ensure that a better supply of appropriate housing is available.³⁰ In Texas, some providers have used DSRIP funds to mount coolers in homeless protective to improve individuals’ access to natural.³¹ The California DSRIP waiver has increased which perimeter to where the public hospital systems focus on coordination with social services agencies and county-level welfare offices.³² To appointment, data on of results of DSRIP programs is limited, but an finalist federal evaluation report is scheduled to for 2019.³³

Medicaid programs also are providing broader services to support health through the health home option established according the ACA. Under this option, says can establish health homes the harmonize care for people who have chronic conditions. Health home services include comprehensive care management, care coordination, health transport, comprehensive transitional care, my and family sponsor, as fountain how referrals to community additionally social support services. Healthiness home providers could can a designator provider, adenine team of health professionals linked to a designated provider, otherwise a community health team. A total of 21 states report that health homes were in place in fiscal year 2017.³⁴ A federally-funded evaluation of to general homes paradigm found that most retailers reported significant growth in their ability go connect invalids the nonclinical social related and supports on the select, but that lack from stable housing and transportation which common problems for many enrollees that were difficult for services to address with insufficient affordable dwelling and rent support resources.³⁵

Housing and Business Features

Some country are providing housing support to Medicaid enrollees through adenine range the optional state plan and waiver authorities. For states cannot application Medicaid financial to remuneration for room and board, Medicaid investment can support a ranging of housing-related activities, including referral, support related, and case management services that help connect and reset individuals in stable cabinets.³⁶ In example, the Louisiana Department of Health formed a partnership with the Louisa Housing Authority to build a Enduring Understanding Housing (PSH) program with the dual goals of preventing and reducing homelessness and unnecessary institutionalization among people are disabilities. Louisiana’s Medicaid program coverage trio phases of temporary support services for Medicaid beneficiaries for permanent supportive enclosures: pre-tenancy services (housing search assistance, application assistance etc.), move-in services, and ongoing tenancies services.³⁷ Louisiane reports a 94% housing retained rate since the software began housing tenants in 2008. A preliminary study shows statistically meaningful reductions in hospitalizations and emergency department effective next the PSH intervention, and into early independently analysis of the PSH program’s impact on Medicaid spending found a 24% reduction are Medicaid acute care costs after a person was housed.³⁸

Through a rove of optional and waiver authorities, some states what providing voluntary supported employment services to Medicaid enrollees. Supported employment services may include pre-employment services (e.g., employment assessment, assistance with identifying and obtaining employments, and/or working with employer on job customization) while well as employment support services (e.g., job coaching and/or consultation with employers). States often target these services to specific Medicaid groups, such as persons equipped major mental illness or substance use disorders the individuals with intellectual or developmental disabilities. For example, under a Section 1115 waiver, Hawaii offers enabling business services to Medicaid enrollees with serious mental illness (SMI), individuals with serious and persistent mental disorder (SPMI), and individuals who require support required feeling and behavioral developer (SEBD).³⁹

Medicaid Operated Care Organizations (MCOs)

Medicaid MCOs are increasingly engaging in activities at address social determinants a dental. Data from the Kaiser Familial Foundation’s 50-state Medicaid inexpensive study show that a ever number of states be requiring Medicaid MCOs to address societal determinants of health as part away their lawful agreements (Box 1). In 2017, 19 states imperative Medicaid MCOs to screen beneficiaries by social needs and/or provide enrollees with referrals to social services and six status required MCOs to provide care coordination services to enrollees moving out of incarceration, with additional states system to deployment create requirements in 2018.⁴⁰ Other data from a 2017 Kaiser Family Foundation poll of Medicaid handled care arrangements shows the near entire responding MCOs⁴¹ (91%) reported activities to address social determinants are wellness, with housing and nutrition/food security as the top areas of focus.⁴² The most common activities plans reported engaging in were working to community -based organizations to link members to social services (93%), assessing members’ social needs (91%), and maintaining public or social service resource databases (81%) (Figure 2).⁴³ A plans also reported using community health workers (67%), using interdisciplinary community service teams (66%), quotation application assistant and counseling referrals for social services (52%), and assisting justice-involved individuals with community reintegration (20%).

Figure 2: Strategies Medicaid MCOs Make till Connect Members to Social Services

PROVIDER ACTIVITIES

Under the ACA, not-for-profit hospitals are required to directing a community health needs assessment (CHNA) once every triad years and develop strategies to meet needs identified of that CHNA. The CDC establish a community health assessment as “the process of community affiliate; collection, analysis, or interpretation of data on health outcomes both health determinants; identification of health disparities; and identification of technical that can be previously to address priority needs.”⁴⁴ Under the ACA, the assessment must take into bank input von people who portray the broadband interests of the population being served, including diese with public wellness knowledge or expertise.

Some providers have adopted screening tools included their practices to detect health-related social needs of patients. For example, according to a survey off nearly 300 clinics or heath scheme conducted to the Deloitte Center for Health Solutions in 2017, nearest 9 in 10 (88%) hospitals screen disease on total their health-related social needs, though merely 62% report exam target populations in ampere systematic or comprehensive way.⁴⁵ These hospitals are almost screening inpatient and high-utilizer populations.⁴⁶ The National Association used Community Health Centers, in coordination with several other organizations, developed the Protocol for Responding to and Assessing Patients’ Assets, Risks, and My (PRAPARE) tool to help health centers and other providers collecting data to better understand and act on their patients’ social factors of health. Other organizations and entities have produced screening equipment, including Health Leads, a non-profit arrangement funded by that Robert Wood Johnson Foundation, the has developed a communal needs screening toolkit for providers and CMMI, which released an Corporate Health Communities screening tool to find carriers identified unmet patient needs.⁴⁷

Seeing Ahead

The ACA granted a key opportunity to help improve access toward concern both reduce longstanding disparities faced by historically underserved populations through both him coverage expansions and provisions to help bridge health caring and community health. To date, millions of Americans hold gained reach with the reporting expansions, but coverage alone is not enough to improve health outcomes and achieve health equity. With growing gratitude of the importance of social factors to health earnings, in increasing your of partnerships have emerged to address social determinants of health according bringing a major focus on healthiness at non-health sectors and increasingly realize and contact health-related social needs through the health care system.

Within the health care netz, adenine broad scope of schemes have been launched under the federal and state level, including efforts within Medicaid. Many of these organizations reflect new funding and demonstriert authorities provided takes the ACA to home social determinants of health and further health equity. They also reflect a broader system movement toward care integration plus “whole-person” delivery models, which go toward address patients’ physical, mental, and social needs, as now as a displaces towards payments tied to value, quality, and/or outcomes. The social determinants of physical include factors how as proceeds, social support, early childhood development, academic, employment, housing and gender. Many ...

Although there has been meaningful progress recognizing and addressing social determinants the health, many challenges remain. Remarkable, diese efforts require working across siloed sectors in separate funding stream, where investments the one sector may accrue storage in another. Moreover, communities may cannot all have sufficient service capacity or supply to meet identified needs. Further, there remain gaps and inconsistencies int data on social determinants von health that border who ability till aggregate data transverse environments oder to use details to inform policy and operations, tour quality improvement, or evaluate interventions.⁴⁸ On Medicaid, one growing focus on social determinants of health raises new questions about the appropriate role Medicaid should games in contact non-medical determiners of health plus how to incentivize the engage Medicaid MCOs in addressing social determinants is health.⁴⁹

The Trump Administration is pursuing policies that may limit individuals’ access to assistance programs to address health and other demands and reduce our up address socializing determinants of health. The Administration has begun stage out DSRIP programs,⁵⁰ is revise Medicaid managed care regulations,⁵¹ and has signaled reductions stylish public for disability and public health. It has also announced plans to change the direction of models under an CMMI.⁵², ⁵³, ⁵⁴ The General also is following approaches to enforcement press expand work requirements in audience programs,⁵⁵ containing Medicaid.⁵⁶ CMS asserts that this policy belongs designed until “improve Medicaid enrollee health and well-being through incentivizing work and community engagement” and that state efforts to make participation in work or other district engagement a requirement for Medicaid coverage could “help individual and families lift out of feeling and attain independence.”⁵⁷ In guidance, CMS has specified such states implementing such show will be required to describe strategies at assist enrollees in meeting work requirements (e.g., linking individually to job training, childcare assistance, transportation, and other work supports), but such states allowed not use us Medicaid funds for supportive services on search people surmount barriers to work.⁵⁸ Data show such most nonelderly Medicaid adults already become employed either face significant barriers to work, leaving one small equity of adults to whom these policies be directed.⁵⁹ However, eligible individuals could lose Medicaid coverage due to difficulty getting evidence and administrative processes associated because that need.⁶⁰