Broadly speaking, the healthcare sector has embraced the concept that identifying and addressing social needs (sometimes referred to as ‘health-related social needs’ specifically) is a necessary component of delivering quality clinical care and improving the health of patients and their families. While some hospitals and clinics have been screening for social needs for much longer, the practice accelerated between 2010 and 2020 in response to a combination of new regulations, increasing evidence of the role non-clinical factors play in health outcomes, growing interest in value-based and risk-based care models and an explosion of technology companies seeking to capitalize on this interest. Today, according to recent studies by Deloitte and the American Hospital Association, more than 80% of all hospitals and an increasing number of health plans screen patients/members for at least one health-related social need, like access to food or safe housing, and most report having a strategy to address identified needs. But how effective are those strategies?
Screen & Refer
When providers began identifying patients’ social needs, most referred patients to community-based organizations (like food banks and homeless shelters) to have those needs met. In the early days, this was done informally, with a printed-out flyer, or via a social worker or volunteer working at the hospital. Eventually, hospitals formed partnerships with organizations like Health Leads and, later, began investing in technology solutions like Unite Us, FindHelp and Healthify to automate this referral process. As the practice grew, so did the demand for results so both non-profits and technology providers designed ways to ‘close the loop’, or report back to providers that the patient did, in fact, seek out the recommended services. While helpful in better connecting individuals with social services, these solutions often resulted in frustration for resource-strapped social service providers and were unable to solve for true outcomes measurement – was the patient actually now stably housed?
Care Coordination
While most hospital systems still utilize screen and refer models, an increasing number are moving towards more intensive models that involve actual coordination of services for vulnerable populations and processes for measuring actual outcomes associated with these efforts. For example:
CommonSpirit designed, in partnership with nonprofits, patients and community leaders, a Connected Community Network model, which they are now implementing in several markets. This model places a nonprofit and the local 211 at the center of a network that includes social services providers, healthcare providers, and health plans and empowers the social service providers to coordinate care for individuals. The work is collaboratively funded by healthcare providers and payers to avoid duplicative and conflicting programming being funded by competing stakeholders.
Similarly, some communities launched Pathways Community HUBs, (PCH) a model first created by physicians who realized the fragmented and siloed ways in which people were trying to access services was doing more harm than good. The PCH model centers Community Health Workers, who support an assigned roster of individuals in achieving social and health outcomes along evidence-based pathways. A neutral nonprofit entity serves as the coordinating entity and contracts with health plans and healthcare providers to fund the work, tying payments to achieving specific outcomes. The model has resulted in improved birth outcomes and is now being implemented for patients with chronic conditions like diabetes.
Direct Interventions
Despite more than a decade of increased focus on the impact social and structural forces have on individual health, the U.S. has generally not made much progress in improving key health outcomes or reducing the prevalence of social needs. Too many people lack sufficient access to food, safe housing, clean air, financial stability and overall safety. To move the needle, the healthcare sector needs to go beyond referring people to or even coordinating access to services. There is a growing movement among providers and plans to do just that – many are directly providing social care interventions while others are meaningfully investing in new and proven programs.
While the lack of housing stock gets a lot of attention (as it should), the substandard quality of existing housing is also a serious health concern. Housing in lower-income neighborhoods, in particular, is plagued by mold, pest infestations, and poor ventilation that exacerbates asthma for children and adults. To reduce emergency room visits, missed days of school and work, and the financial burden of recurring asthma attacks, hospitals like the Children’s Hospital of Philadelphia are investing in community-led initiatives to improve housing conditions. Others, like Children’s National in Washington, DC have launched Medical-Legal Partnership programs to connect patients with pro-bono legal support to ensure landlords and property owners comply with housing quality standards.
Food and nutrition security is the most common domain for which hospitals screen patients and lacking access to sufficient food is linked to numerous health conditions and poor health outcomes. Several hospitals have gone beyond providing food to patients to actually producing food as well. For example, Boston Medical Center recently opened its second rooftop farm, producing food for patients and local food banks. Similarly, ProMedica owns and operates a farm in southern Michigan that not only provides fresh produce for the hospital’s patients but also serves as an outdoor space in which occupational therapists conduct sessions and contributes to patient mental health.
Going Upstream
Ultimately, achieving large-scale, sustained results in health outcomes by addressing social factors will require both upstream and downstream efforts, as well as cross-sectoral collaboration. Most healthcare institutions are not yet working upstream in significant ways, but there are some early bright spots, most of which are collaborative and focused on both leveraging institutional assets and advocating for public policy changes. For example:
Now in its fourth cohort of three-year awards, the BUILD Health Challenge was launched by the de Beaumont Foundation to galvanize local collaboratives of nonprofits, healthcare providers and public health agencies to address pernicious health issues. A wide range of funders pool resources to support communities selected through a competitive application process and de Beaumont provides ongoing technical assistance, evaluation services and facilitated peer-to-peer learning opportunities. Collaboratives that have participated in the program have changed local policy, created and revitalized community spaces, and launched new programs to address health disparities.
Launched in 2018 by the Lincoln Land Institute’s Center for Community Investment, the Accelerating Investments for Healthy Communities program was a three-year program for health system leaders from across the country. The inaugural cohort included UPMC, Nationwide Children’s Hospital and four other systems who each partnered with communities to increase the availability of affordable housing in disinvested areas. By the end of the program, participating systems had deployed $31M in resources and secured $500M in additional government funding to create and preserve more than 1,200 affordable housing units.
Founded in 2016 by 40 health systems, the Healthcare Anchor Network (HAN) is a national membership organization that aims to increase the extent to which hospital systems leverage their assets to invest in their communities, increase local hiring and sourcing practices and reduce environmental impact, improving local economies and resident health. HAN engages members in peer learning opportunities, documents innovative work through case studies, and holds members accountable to mutually agreed upon goals across its core pillars.
Building Momentum
As the sector continues to test and evaluate approaches to addressing social barriers to health, we will likely see more investment in each of these categories. At the same time, the sector has also moved into even broader strategies to improve community health and well-being, namely place-based investing and impact investing efforts that seek to achieve a variety of goals through multi-pronged, layered efforts over longer time horizons. Continued work along each of these vectors will be critical to moving the needle on health outcomes for decades to come.
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