Supporting Health Care and Community-Based Organization Partnerships to Address Social Determinants of Health

Increasingly, health systems, providers, and payers recognize the significant influence that social factors such as housing, food insecurity, employment status, and transportation have on well-being and health care spending. These social determinants of health (SDOH), in addition to health behaviors, influence 80 percent of health outcomes in the United States, and disproportionately affect low-income populations (Hood et. al. 2016). As reimbursement models transition away from fee-for-service to value-based payment, there has been a greater focus on innovative models of care that integrate medical and nonmedical services to improve health outcomes. Such demonstration projects include: Accountable Health Communities (an effort by the Center for Medicare and Medicaid Innovation to test whether identifying and addressing the social needs of Medicare and Medicaid beneficiaries can reduce health care costs/utilization); accountable communities for health (state-led cross-sector efforts to improve population health); and accountable care organizations. While these models differ in scope, structure, and target population, they generally rely on establishing a new breed of partnerships between health care and community-based organizations.

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