Improving the SDH System of CARE: Lessons From Safety Net Providers

Sg2 Analytics Spotlight

Coauthored by Matthew Vestal, Director of Client Relations, Sg2

As our industry moves toward managing the health of individuals beyond the walls of traditional care settings, we must also take steps to broaden our definition of the System of CARE. No longer are health and wellness confined to doctor’s visits, procedures and prescriptions.

Data indicate that only 10% of health outcomes today are attributable to direct medical care and 30% to genetic predispositions, while a staggering 60% of outcomes are tied to social and environmental factors and the personal behaviors influenced by those factors—also known as social determinants of health (SDH). Safe housing, transportation and food security are just a few barriers to good health facing millions of patients—most notably the more than 70 million Americans receiving Medicaid today.

Industry professionals have long recognized the importance of SDH in treating chronic diseases, though resources to address these issues have been limited. However, the volume to value shift is challenging providers to think along these lines. Changing financial incentives are placing the onus on providers to address the health needs of patients in the most cost-effective setting, which often means outside the hospital or physician office.

The need to address behavioral and social needs of patients is more critical now than ever before. The US Department of Health and Human Services agrees. Just a few weeks ago, the CMS Innovation Center announced a $133 million funding opportunity to help bridge the gap between health care delivery and social services.

Safety Net Hospitals Were Pioneers in SDH
The safety net provider has been driven by its mission to provide care to the most vulnerable: the poor, those without insurance and populations largely dependent on Medicaid. Like Levi Strauss with jeans and Henry Ford with the automobile, safety net providers have proven to be unwitting pioneers in their field, making the SDH System of CARE cool before it was cool. By investing in partnerships and programs that address the social, environmental and behavioral needs of patients outside of the traditional medical setting, safety net providers have provided their peers with a blueprint in which their own SDH Systems of CARE can be mapped. This is population health 101.

However, navigating the complex social services landscape to connect patients with basic resources often feels like an enormous obstacle. Broaching personal issues like housing and food and job security with patients was not a required course in most medical schools. Many clinicians’ stories sound like this:

“I prescribe a controller medication for the child with an asthma exacerbation who comes into my clinic, but the truth is, I know his family is living with 12 other people in a dilapidated, mold-infested apartment. And I know there’s no food at home. I don’t ask about those issues because there is nothing I can do. I have 13 minutes with each patient, with more piling up in the waiting room, and I have nowhere to turn for help.”

Partnerships Are One Approach to Improve Your Population’s SDH
One solution hospitals and health systems can consider is partnership with community organizations to focus on and improve SDH of their populations.

For example, the social enterprise Health Leads envisions a health care system that addresses all patients’ basic resource needs as a standard part of care. It partners with leading health systems across the country to improve SDH. Launched in 1996, Health Leads provides consulting, tools and education to build sustainable social needs programs and also embeds Advocates—college students, community health workers and others—into health systems or clinics, both on-site and remotely. These Advocates connect families and patients to community-based resources, from healthy food to transportation to health insurance.

These engagements have yielded a range of interesting results and findings:

  • The demand for social needs support is more than meets the eye. While most health systems collect thousands of data points about their patients, understanding patients’ psychosocial needs is a “black box,” as an SVP of quality at one integrated delivery system explained. One academic medical center estimated its screen positive rate for basic resource needs would reflect its Medicaid population: just under 20%. The reality: 58% of screened patients had a positive screen for basic resource needs.
  • Addressing social needs improves clinical outcomes. Recent data also show that addressing social needs can directly improve outcomes and quality measures. A recent Massachusetts General Hospital study found that addressing patients’ unmet social needs (through Health Leads) was associated with clinically meaningful improvements in patients’ LDL-C cholesterol and blood pressure.

Consider Creating Your Own Community Outreach Programs
The Sinai Community Institute, part of the Sinai Health System in Chicago, addresses the SDH System of CARE for its population using a homegrown model.

Twenty-five years ago, Debra Wesley, a social worker on the West Side of Chicago, was frustrated. She felt her work in family planning should address the many social and family challenges her clients faced in addition to providing contraception.

Soon she had secured money and space for a community center dedicated to programs that address SDH. The Sinai Health System and the greater community recognized the need to address health needs beyond medical care, and 25 years later, the Sinai Community Institute (SCI) is thriving. It provides 28,000 visits per year through a variety of community programs including the following:

  • Women, Infants and Children (WIC) program at SCI is the largest private WIC program in Illinois, providing nutrition education and appropriate food to infants, children and pregnant women.
  • SCI provides a WIC Culinary Program to provide breastfeeding and pregnant mothers with basic cooking techniques such as roasting, baking and steaming to facilitate healthy lifestyle choices. Its goal is to minimize deep fat frying and encourage healthier cooking.
  • The Sinai Affordable Care Act Counselor Project enrolls identified eligible individuals in and educates them about qualified health plans.

What makes this model work? According to Debra, “it all goes back to understanding that it’s about relationships, and there are no shortcuts.” When doctors were frustrated at the high number of patients missing appointments, the community pushed back. Without evening appointments, the cost of going to the doctor was too high. Hence began a dialogue resulting in expanded clinic hours, which satisfied the community’s need for flexibility.

Debra continues to ask the community, “What does healthy look like? How is this community different, and what are our core competencies?” Key to success is taking a seat at the table along with other community leaders. Competitors become partners, united to promote health and well-being. Health systems are increasingly seeing the value of screening for and navigating patients to basic resources—and many are making it a standard of high-quality patient care.

Sg2 Analytics Can Help You Identify Areas of Need
Sg2 analytics can be used to hotspot diseases and neighborhoods in which developing partnerships or programs to improve the SDH System of CARE make sense. In the blinded example below, we prioritized 6 chronic conditions with high forecasted outpatient growth. These conditions had staggering potentially avoidable admission (PAA) rates. PAAs by definition are conditions that with proper management should not result in an admission.

Using our market forecasts, we can identify the zip codes where these patients live, and using market demographics, we can tailor services appropriately. Culturally competent care, or understanding needs based on language, diet and culture is a critical component for success.


This type of information can be used to focus your organization’s efforts to improve your population’s SDH. For example, Children’s Health in Dallas, TX, a children’s hospital with its own health plan, identified asthma as a key disease to prioritize. It created a robust community health program to support kids at school, church and home, which included partnerships with local schools and the local YMCA. These partnerships decreased ED visits and readmissions for asthma. Children’s Health even performed home environment checks for some of its kids with asthma, with suggestions to minimize potential asthma triggers.

The safety net community has found a way to manage highly complex patient populations by developing sophisticated and cost-effective SDH Systems of CARE. Let their experience, along with Sg2’s robust suite of analytics, guide your thinking about how to best address the significant social determinants of your population’s health.

Editor’s Note: Susan McCarron, Principal, Strategic Communications from Health Leads, contributed to this post.

Sources: Sg2 Interview With Sinai Community Institute, 2015; Sg2 Interview With Health Leads, 2015; Health Leads website; Sinai Community Institute website; McGinnis JM et al. Health Aff (Millwood). 2002;21:78–93; Sg2 Analysis, 2016.


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