The importance of targeting social determinants of health for population health initiatives: 3 key takeaways

Up to 80% of health outcomes are influenced by factors beyond clinical care such as economic wellbeing, housing, food insecurity, and other community and social factors.¹ These social drivers can create gaps in care.² 

In an interactive session at Becker's Hospital Review’s 11th Annual CEO + CFO Roundtable, Christen Buseman, PhD, director of health system solutions and general medicine at Amgen, and Trenor Williams, MD, co-founder and CEO of Socially Determined, facilitated a discussion on how social drivers of health influence population health interventions across the patient care continuum. Roundtable participants — including chief executive, nursing, clinical, quality and innovation officers at hospitals and health systems across the United States — discussed their organizations' current interventions and why collaboration is necessary to scale their efforts.

Three key takeaways were:

1. Understanding social determinants of health (SDOH) at the community and individual level is critical to reducing health disparities and improving patient care. With only 20% of health outcomes driven by access to care and quality of services, physicians only have a partial view into their patients’ health challenges.³ “Social drivers of health play into every step along the care continuum,” said Dr. Christen Buseman. Dr. Trenor Williams also agreed, “ZIP codes can be more important that your genetic code,” and he added that national organizations such as Centers for Medicare & Medicaid Services, National Committee for Quality Assurance and The Joint Commission are encouraging health systems to track social drivers of health as well as health equity metrics.
   
   
2. Thanks to industry-wide focus on social drivers, areas of care that have always screened for SDOH are getting more support. Hospitals and health systems are seeing early successes and improved health outcomes in SDOH-based interventions. There is broadening market awareness about the impact of social risks, and health systems are taking action.⁴ Health systems are in a unique position to champion social risk efforts because of their relationship with patients, the trust they have developed and their ties to each local community they serve.
   
   Roundtable participants highlighted several examples of how health systems are implementing creative solutions to close gaps in care – from starting food pantries to pushing community health workers to go to people's homes to minimize the digital divide.
   
   
3. Health systems continue to experience challenges when it comes to scaling and measuring impact of interventions. Data collection to track program progress can be difficult and expensive because person-level social risk data may be gathered inconsistently and raw data elements could have high overhead costs.⁵ “There is clearly an impact, but the cost is at times prohibitive and whatever reimbursement is available doesn't cover the costs,” said a Senior Vice President of Population Health at an East Coast Academic Health System. As other stakeholders, including health plans, employers, and community-based organizations, gather SDOH data and lead SDOH interventions, the industry will need to work on data sharing and integrated community efforts.

Despite these challenges, roundtable participants were optimistic that health systems will continue prioritize implementing interventions that address SDOH. “The good news is there is more interest, more investment, more work going on this space than ever before,” said Williams.

Editor's note: Quotes have been edited for length and clarity.

1. Greer ML, Garza MY, Sample S, Bhattacharyya S. Social Determinants of Health Data Quality at Different Levels of Geographic Detail. Stud Health Technol Inform. 2023;302:217-221. doi:10.3233/SHTI230106
2. Hood, CM et al. Relationships Between Determinant Factors and Health Outcomes. Am J Prev Med. 2016;50(2):129-135. https://www.ajpmonline.org/article/S0749-3797(15)00514-0/fulltext
3. Greer ML, Garza MY, Sample S, Bhattacharyya S. Social Determinants of Health Data Quality at Different Levels of Geographic Detail. Stud Health Technol Inform. 2023;302:217-221. doi:10.3233/SHTI230106
4. Horwitz, L. Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19. Health Affairs. 2019; 30 (2)
5. Socially Determined. Pharmaceutical Executive webinar recap: SDOH Data Evolution, 2023.