Addressing Social Determinants of Health: The Key to Patient-Centered Care

For far too long, the American health care system lacked economic support to address health-related social needs (HRSNs) effectively. It has been well-known for many years that social determinants of health (SDOH) have a dramatic impact on population health and outcomes, evidenced by efforts like Healthy People 2020. Finally, we are seeing both the public and private sector actively integrating SDOH into payment models and quality reporting. Now providers are beginning to receive payment for identifying and addressing SDOH to prevent the development and progression of costly chronic diseases.

The Shift in Incentives: CMS’s Focus on Health Equity

In 2016, CMS launched the Accountable Health Communities model – a five-year pilot program designed to test the effectiveness of addressing SDOH on improving outcomes and reducing costs. The model created a framework for bridging the gap between clinical care and community services by providing support and resources to address housing instability, food insecurity, and transportation barriers. A recently released report about the model showed:
• Fee-for-service Medicare and Medicaid beneficiaries that received navigation services (i.e., screenings for SDOH, education on resources, assistance with benefits enrollment, appointment and referral coordination, and ongoing support to navigate healthcare and social service systems) had lower emergency department use than those who did not receive navigation services.
• Medicaid beneficiaries with multiple unmet HRSNs had larger expenditure and hospital utilization reductions than those with one HRSN.
• Non-white and/or Hispanic Medicare beneficiaries had more significant reductions in expenditures and hospital utilization than non-Hispanic White beneficiaries.
These report findings support that addressing SDOH improves health equity and reduces healthcare utilization.

These results were good enough to spur CMS into building SDOH and health equity considerations into new models. For example, CMS’s added Advance Investment Payments to the Medicare Shared Savings Program (MSSP) to encourage doctors, hospitals, and other providers to form Accountable Care Organizations and work with Community-Based Organizations (CBOs) to screen and manage HRSNs. CMS also announced the Making Care Primary (MCP) model, which pays primary care organizations to identify and address HRSNs, connect patients to community services, and manage chronic diseases to reduce unnecessary emergency department visits.

Download our report, A New Dawn For The Healthcare Industry’s SDOH Strategy

Improving Population Health through SDOH Interventions

The connection to CBOs is an important part of these models. CBOs are uniquely positioned to provide a wide range of social services, helping address the underlying social needs that impact health outcomes, leading to improved population health.

These services are vital to prevention and early intervention in healthcare, limiting the progression of costly chronic diseases. For example, a recent initiative to offer home-delivered meals to patients admitted for heart failure and other acute medical conditions showed that exposure to posthospitalization meal delivery decreased 30-day rehospitalization and mortality.

Whether for food insecurity, housing instability, transportation barriers, or other HRSNs, referring individuals to CBOs and closing the loop on those referrals fosters care coordination and collaboration, enabling a more holistic and patient-centered approach to care. One of the nation’s leading social care referral networks is findhelp.

Clearly, addressing SDOH is essential for population health, but it also offers an opportunity for providers. Some payers, including government programs, recognize the value of healthier populations, leading to implementing reimbursement policies that support providers in addressing SDOH. Also, offering these services can assist providers in attracting and retaining a broader patient base. While upfront investment is necessary, improving outcomes, participating in new value-based care models, and attracting new patients can generate long-term financial benefits for providers.

Integrating SDOH into Quality Measure Reporting

The transition to value-based payment models and integrating quality reporting into reimbursement systems is ongoing. However, traditional quality reporting primarily focuses on clinical outcomes and processes, such as mortality rates, readmission rates, and adherence to clinical guidelines – often overlooking patient perspective and prioritizing acute care and treatment of diseases rather than preventative care and wellness. This limitation in reporting hinders efforts to shift healthcare to a preventative approach, leading to higher costs.

The National Committee for Quality Assurance (NCQA), a non-profit organization focused on improving healthcare quality, introduced a new HEDIS measure in 2022 – social needs screenings and interventions. Specifically, this measure was designed to encourage health plans to address their populations’ food, housing, and transportation needs.

NCQA also launched its Race and Ethnicity Stratification Learning Network to help payers identify and share best practices and strategies for improving the overall collection, management, and use of race and ethnicity data. While NCQA began implementing race and ethnicity stratification to HEDIS measures in Measurement Year (MY) 2022, the organization continues to expand the number of measures with this stratification. It is clear that health equity is now an important indication of quality.

In talking about equity, collecting and analyzing race and ethnicity-stratified SDOH data is required to address disparities. Targeting the correct populations and creating tailored interventions is vital in allowing organizations to allocate resources effectively in healthcare.


Given these recent actions, payers and providers must be ready to respond to the changing landscape of SDOH in healthcare and its impact on utilization and cost. Collaborative efforts with CBOs and industry partners, like Uber, play a vital role in delivering impactful interventions to meet the underlying needs of patients. By partnering with technology solutions to collect and analyze race and ethnicity-stratified SDOH data, healthcare organizations can effectively tailor solutions to create long-term benefits for themselves and consumers. Acting now not only enhances patient care but also supports the transition toward a value-based, patient-centered approach to healthcare.

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