4 Top Successful Social Determinants of Health Programs

Here are four programs making a difference.

There’s a reason that healthcare systems address social determinants of health (SDoH): Studies show that when patients have stable housing, nutritious food, and transportation to medical visits, their health improves and their use of the most expensive medical services, like visits to the emergency department (ED), decreases. SDoH are conditions that affect a person’s health, like where they live, their educational and socioeconomic status, and their social support networks. Healthcare systems around the country address various aspects of SDoH, whether in new, small pilot programs, or larger well-established ones.

Some of the most innovative programs are run through Medicaid plans. The Kaiser Family Foundation conducted a 2017 national survey of Medicaid managed care organizations, showing that more than 90% of plans run at least one SDoH program. “They are responding to what they see as needs in their community, and building around those needs,” said Jennifer Babcock, vice president for Medicaid policy at the Association for Community Affiliated Plans (ACAP), a national trade association representing not-for-profit safety net health plans, located in Washington, D.C.

Here are four programs making a difference.

Healthy Together

Until April 2018, when Alliance for Better Health IPA practices in upstate New York wanted to make a referral to a social services organization, they consulted a resource guide. The problem? The resource guide was out of date even before it was published, as new programs popped up frequently.

“If we, as providers, struggle with that, you can imagine the burdens that our community members have accessing them,” says Michele Horan, the director of operations for the Healthy Together platform. Instead of providers calling, faxing, and emailing community-based organizations (CBOs) for referrals, they can now go through a web-based platform tying them all together. Healthy Together is the Alliance’s branded name for the Unite Us platform, integrating health and social care. Providers can now send and track referrals in a closed loop, documenting patient situations once so they don’t have to repeat their stories to every new agency.

“All the partners can communicate with one another (in Healthy Together) to ensure that someone doesn’t fall through the cracks,” says Keshana Owens-Cody, Alliance’s senior director of partner success.

Social service providers enroll in the network for free. Healthy Together currently has 20 service categories, 132 subcategories, and 75 enrolled organizations with 275 programs included. It actively recruits organizations to join the network and help onboard them. Given the relatively short time frame it’s been live, Healthy Together has not yet parsed the data to look at outcomes, but anecdotally it is thrilled with its connectivity, transparency, and ease of use.

Wellness on Wheels

Since starting its Wellness on Wheels mobile primary care clinic three afternoons a week in January 2017, OhioHealth decreased inappropriate ED visits by 50%. The healthcare system started its Hilltop neighborhood clinic in the YMCA parking lot in an impoverished and medically underserved neighborhood not far from one of its hospitals. Community health workers in the hospital setting encouraged patients to establish care at the mobile clinic, as many don’t have primary care physicians.

The Hilltop clinic is an expansion of the OhioHealth women’s health clinic, with a 26-year history. The 54-foot mobile unit has two exam rooms, housing clinicians and a social worker who screens for SDoH and make referrals in both settings, says Shannon Ginther, OhioHealth senior director of community health partnerships.

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