With changes in the federal funding landscape for health related social needs, we are at an innovative time in the SDOH landscape. Government and community based organizations are joining together to provide coalitions of services to address SDOH needs beyond the doctor's office.
While social determinants of health (SDOH) have clear, inequitable impacts on health outcomes, more and more organizations are beginning to recognize the value in addressing these to promote overall health. This is an up-and-coming space, with room for growth, and plenty of evident innovation. This is even recognized by the federal government, with recent changes by the Centers for Medicare and Medicaid Services (CMS), mandaring all healthcare payers and providers move toward a Value Based Healthcare model and providing the financial support to do so.
To effectively address SDOH, there is strength in numbers. We’re currently in the experimental phase of SDOH initiatives to see what actually works, but it all has to do with working with the community on SDOH issues and meeting people where they are. Some of the most innovative and impactful initiatives are being run by coalitions of nonprofits in regional areas, facilitated by a backbone administrative entity. This is because SDOH are complex and wide reaching, but also intertwined. While addressing one determinant, like food insecurity, provides clear benefits, something like food insecurity is also closely linked to financial instability, housing, and transportation. Therefore, impact is maximized through efforts that address multiple SDOH.
One example, the Cross-sector Innovation Initiative (CSII) co-led by The Center for Sharing Public Health Services (CSPHS) and Public Health National Center for Innovations (PHNCI), promotes the alignment of governmental public health departments with other sectors to improve population health through cross-sector partnerships. So far, there have been 10 grantees in communities across six states, like the Better Health Together Collaborative in Washington that aligns organizations to address housing costs, behavioral health services, and family violence and trauma.
Organizations in San Diego, California are also aligning through the Live Well San Diego initiative. With over 500 members operating since 2013, this coalition includes organizations across sectors, like nonprofits, schools and faith-based groups, businesses, and government. Gatherings occur by region and sector, and partner organizations identify priorities and plan ways they can improve their community. These efforts resulted in a 12% reduction in deaths by preventable health threats. This coalition has had monumental impact within the area. In 2023, they reported $150.1 million of grant money awarded to their nonprofit members, 8060 people housed, and 418,140 referrals given to address individual SDOH related needs.
Government regulations regarding health funding and SDOH are also changing enabling states to progressively use federal dollars to address health related social needs through initiatives like community care hubs.
Michigan is one state doing just this. Their pilot program, Social Determinants of Health Care Hubs, brings together healthcare providers, non-profit organizations, and business leaders to address health equity through SDOH services. Launched in early 2024, these pilot sites work to identify SDOH needs, then link patients to community services that may address these needs. This program emphasizes the need for better technological documentation and follow-up, coordination between entities, and community-based work.
Similarly, North Carolina is piloting three regional Network Leads that bridge the gap between healthcare providers and social services to maximize SDOH efforts. As singular hubs, they will utilize Medicaid funding to coordinate and deliver services regarding transportation, housing, personal safety/healthy relationships, and food. There is a diverse group of several hundred community-based organizations across this coalition, such as the Appalachian Sustainable Agriculture Project, Community Housing Coalition of Madison County, and Maccon Program for Progress.
Other states are innovatively paving the way to use federal healthcare dollars to address SDOH within local communities, and Pennsylvania is following. The currently pending initiative, Bridges to Success: Keystones of Health, proposes to use Medicaid funding to target child health coverage, housing, food and nutrition, and reentry from correctional facilities. With work guiding the cross-sector collaboration between healthcare organizations and community-based organizations, Pennsylvania can lean into untapped potential to better health outcomes across the state.
To cite: Hygieia Consulting. (2024) What's Working in the Social Determinants of Health Space?. hygieia.llc
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