In the ongoing pursuit of improving public health outcomes, tackling Social Determinants of Health (SDOH) has emerged as a top concern for regulatory agencies and community-based organizations (CBOs) across the United States. This prioritization stems from recognizing that individuals’ well-being is not solely determined by access to healthcare services but is profoundly influenced by social and economic factors such as housing, nutrition, and education. Failure to resolve these health-related social needs (HRSNs) might increase people’s likelihood of developing serious health conditions like stroke, cancer, depression, diabetes, and heart disease.
To spearhead nationwide efforts, the Biden-Harris Administration has published the first-ever U.S. Playbook to Address Social Determinants of Health. In our most recent blog post, we have synthesized the first half of the Playbook, including four main socioeconomic concerns related to SDOH and federal measures undertaken to tackle these issues. However, the primary focus of this publication is to offer a multi-pillar solution to SDOH, encompassing enhanced health data practices, flexible utilization of funding, and support for backbone organizations. In line with the U.S. government’s approach, the Network for Nonprofit and Social Impact has studied Systems of Care, which are organizational arrangements designed to support individuals in locating and obtaining valuable benefits, programs, and services to meet their HRSNs.
Continue reading this blog post to learn more about the intersection between the Playbook’s multi-pillar solution to SDOH and the NNSI’s research on Systems of Care.
Pillar 1: Expand data gathering and sharing
Under this pillar, the Playbook aims to foster an interoperable health and social care ecosystem where data can be captured, analyzed, and exchanged securely and effectively. Proposed measures, with the support of federal, state, local, tribal, and territorial entities, will increase the capacity for data gathering and sharing and thereby allow for more comprehensive care services. One notable initiative is the launch of the SDOH Data Working Group, which draws upon best practices and resources to explore how federal agencies can integrate SDOH data into implementing new policies. Moreover, the Playbook calls on the Centers for Disease Control and Prevention (CDC) to publish data on social needs like food, housing, and transportation to cultivate a better public understanding of the SDOH burden in certain regions.
NNSI Recommendations:
- Create a national resource directory with federal funds in each state: Instead of maintaining individual resource databases, health and social care providers nationwide should work together to create an SDOH community resource directory. With data interchange formats like the Human Services Data Specification, organizations can now easily share resource data across multiple platforms, including websites, mobile apps, call centers, and printed directories. To incentivize these data exchange practices, federal agencies such as the Department of Health and Human Services (HHS) should allocate additional funding to each state specifically for establishing and maintaining the national resource directory.
- Adopt interoperability guidelines from the Gravity Project for SDOH data: Currently, the SDOH data landscape is marked by multiple conflicting standards, preventing healthcare, public health, social care services, and other data systems from integrating seamlessly. The best solution for this would be to implement a standardized case management system based on recommendations from The Gravity Project. This national public collaborative develops consensus-based guidelines to improve SDOH data sharing. The Office of the National Coordinator for Health Information Technology has already made progress in establishing a common data standard, including incorporating Gravity-defined elements in the United States Core Data for Interoperability.
- Fund evaluation hubs to better track SDOH services’ demand and quality: Federal agencies need to invest more resources in evaluation hubs that can measure the capacity of organizations to address SDOH and the demand for those services from community members. This additional funding would allow for the collection of more comprehensive SDOH data on accuracy (if each service episode was routed to the right provider), efficiency (the time it takes for clients to receive care), and effectiveness (if the appropriate service was successfully provided). Such an investment is crucial for improving the quality and impact of SDOH interventions and ultimately advancing community health outcomes.
Pillar 2: Support flexible funding to address social needs
The objective of this pillar is to promote adaptable use of funds across sectors to enable better resource allocation for HRSN manangement. Since organizations often receive funding from various sources and need guidance on allowable ways to coordinate them, it can take time to determine how funds should be utilized to maximize impact. To tackle this problem, the Playbook recommends using Medicaid funds on SDOH interventions, supported by the clarification in lieu of services (ILOS) that states can leverage to offer alternatives to standard healthcare. Besides, it also advocates for increasing payment for SDOH screening in clinical settings so that healthcare providers can better assess HRSNs, thus facilitating access to community-based services to meet those needs.
NNSI Recommendations:
- Ensure that CBOs addressing HRSNs are compensated fairly for their services: Currently, most CBOs still rely on temporary funding, which poses challenges for them in expanding the scale of operations and fostering long-term sustainability. Even when CBOs feel confident in their ability to cater to an increased need for SDOH services, their financial records reflect a notable lack of resources. As a result, the federal government must adopt innovative funding and support mechanisms to ensure that CBOs are financially capable of accommodating the rising number of people referred for services, thereby closing the loop on referrals.
- Change funding models to promote resource referral technologies among CBOs: Despite the benefits of resource referral technologies in connecting patients to nonmedical resources, many CBOs are reluctant to adopt these tools, with funding being one of the contributing factors. Several organizations already have another client management system in place, often as a funding requirement. Thus, a greater incentive to join a new platform must be created, and more funding is needed to integrate platforms through a standard API (e.g., HL7 FHIR). This upgrade in resource referral technology would streamline operations, increase efficiency for CBOs, and improve patients’ access to vital nonmedical resources.
Pillar 3: Support backbone organizations
With this final pillar, the Playbook calls for establishing community backbone organizations and additional infrastructure to connect healthcare systems with CBOs, especially those focused on SDOH. This type of entity functions as central coordinating hubs that link individuals in need with appropriate service providers. However, they can face immense obstacles regarding sustainability, data collection, and partnership development. In response, the Playbook introduces a National Learning Community to enhance the capacity of nearly 60 community care hubs by providing technical assistance, facilitating resource and information exchange, and offering expert consultations on various topics. Another proposed initiative is the sponsorship of five Health Equity Research Hubs, which will benefit backbone organizations by offering research training and capacity building to deliver and evaluate health equity structural interventions.
NNSI Recommendations:
- Improve navigation design tailored to region-specific characteristics: Various CBOs work together to form a navigation system that helps individuals chart the path to appropriate care, bringing their unique resources, including human navigators, referral platforms, and intervention efforts. These elements interact with each other in different ways, usually creating one of the four primary navigation designs: community connectors, demanded directories, healthcare developers, and system integrators. Considering the pros and cons of each design, federal agencies can assist backbone organizations by providing funding and guidance on how to adapt navigation systems to best relieve the SDOH burden in specific regions.
- Invest in models that pair the right human resources with the right technology: Human navigators play the most crucial role in systems of care, but they have tremendous support from technologies like call center platforms, case management software, and resource referral systems. Therefore, social workers, community outreach advocates, coordination center employees, and other contributors must be provided with suitable tools to help address individual-level HRSNs and community-level SDOHs. This change can be achieved through investing in infrastructure upgrades within CBOs, offering additional technical training for human navigators, and promoting interactions between technology users and developers.
- Foster collaboration between CBOs that cater to veterans’ HRSNs: Veterans, service members, and their families often seek a variety of assistance, yet they still fail to receive integrative, high-quality care due to the lack of coordination between veteran-serving organizations (VSOs). Our research finds that veterans frequently demonstrate co-occurring needs regarding employment, mental health, housing, finances, and physical health, which can only be effectively addressed if VSOs work together to offer more diverse programs and benefits. This holistic approach will ensure that veterans and military-connected individuals can obtain comprehensive support that addresses all aspects of their well-being within an integrated health and social care ecosystem.
Although the Playbook has outlined specific actions to address SDOH under three separate pillars, it needs to take a more comprehensive and coordinated approach to tackle health equity challenges once and for all. Here is where our research on Systems of Care comes in, as it offers a framework for integrating services and supports across multiple sectors to meet demonstrated HRSNs. If you want to learn more about this topic, our free presentation can answer common questions about the problems that Systems of Care solve and how to navigate them.
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