Evaluating a Population Health Approach to Addressing Social Determinants in the Community
Statement of Problem
Social determinants of health (SDOH), such as food insecurity and unstable housing, can lead to disparities in health outcomes, preventable use of health care services and increased health care costs. A growing body of research, including some of our own here at PolicyLab, suggests that screening to address SDOH within health care settings is a feasible endeavor and can lead to increased overall quality of care. There’s also emerging research that if health systems and community organizations work together to implement interventions, it can lead to fewer emergency department visits and improved health outcomes.
Despite evidence suggesting that social needs critically impact patients’ capacity to manage their and their child’s health conditions, very few large-scale, collaborative interventions exist that utilize the health care system to connect families to community support services. For those interventions that do exist, we lack evaluations that can help us understand their true impact and inform improvements so all patients can receive care to meet their basic living needs.
Description
Through this project with Intermountain Healthcare, Camden Coalition, and the Perelman School of Medicine at University of Pennsylvania, we evaluated a Utah-based population-level intervention that aimed to improve health outcomes and reduce health care utilization costs by aligning social services and care delivery for patients with high social and medical need. This intervention included screening patients for SDOH needs, connecting patients with community health workers and care teams, and facilitating collaboration between community organizations. Our mixed-methods approach to evaluate Intermountain Healthcare’s efforts will illustrate how health outcomes and health care utilization are impacted by providing social need resources and supporting patient navigation of the health care system.
We learned from patients about their experiences with the intervention, including SDOH screening, the community health worker program and community resource referrals. Interviewing patients helped us to better understand the impact of the intervention on their medical and social needs as well important feedback for improving the intervention. We also interviewed health care and community organization stakeholders about their implementation strategies and experiences, allowing us to better understand common barriers and facilitators to successful implementation.
In order to evaluate the intervention’s effect on patient-level outcomes such as health care service utilization and costs, we worked with Intermountain Healthcare to conduct a comparative-effectiveness trial within the communities that received the intervention. Our project examined how screening patients for SDOH needs and connecting patients with community health workers and/or care management impacted their health care utilization and costs.
We also sought to examine relationships among community organizations serving patients with high social and medical need as well as relationships between community organizations and health care organizations. We conducted a social network analysis to understand the dynamics of and changes in the network of health care and social care services in the communities receiving the intervention.
Finally, we sought to understand how policies and policy change could impact the sustainability of such efforts. PolicyLab, in collaboration with Intermountain Healthcare, Gardner Policy Institute, and Leavitt Partners, worked to better understand the policy landscape and best practices for developing and implementing funding for the intervention, focusing on community health worker program sustainability. We conducted interviews with state and federal policymakers and developed an analysis of Utah state policies and practices.
Next Steps
Throughout our evaluation, we developed recommendations for improving the effectiveness of screening for SDOH and connecting patients to community support services through Intermountain Healthcare’s intervention. We continue to work to disseminate our research findings and recommendations for policy approaches to strategically targeted audiences who can support efforts to integrate SDOH interventions into clinical practice and finance them with existing state and federal programs.
Ultimately, through this evaluation and partnership, we hope to identify how health care systems can best connect patients to community services that address their social needs. In doing so, our goal is to generate first-of-its-kind knowledge about this kind of large-scale health system intervention in order to create sustainable mechanisms to improve the health outcomes of children and adults by addressing SDOH.
This project page was last updated in July 2023.
Suggested Citation
Children's Hospital of Philadelphia, PolicyLab. Evaluating a Population Health Approach to Addressing Social Determinants in the Community [online]. Available at: http://www.policylab.chop.edu. [Accessed: plug in date accessed here].