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health literacy education provided to the
member, caregivers and family helped resolve
the social and physical issues surrounding
the member’s care. The member did not
have any ER visits during the next six months.
He commented that he is much more
comfortable, less fearful and is now able to
visit his family more often.
How To Get Started
To be most effective, healthcare programs
must account for the health of the patient,
their family and support group, their social
needs and their community. It’s only then
that programs can put the resources in place
appropriately (both individually and at a
community/group level) to achieve optimal
individual and population health outcomes.
There is a long list of issues to address and
programs may need to evolve in stages over
time. But there are some initial steps that
can be taken to begin addressing the social
determinants of health:
• Determine how your state, county or city
is currently organized and what structure
or structural changes are needed to foster
collaboration across programs/agencies
• Detail current internal and external funding
streams and determine what changes need
to be addressed
• Determine what programs and services
should be addressed and prioritize
their staging
• Develop inter-agency agreements needed
to foster integrated service delivery
• Determine how client cases would be
managed across programs
• Address security and privacy issues
• Address workforce staffing and
training issues as well as the education
of program members
Xerox can help you think through and
plan strategies to help you incorporate
population health management, integrated
service delivery and social determinants
of health into your program. Email
for
more information.
In the Summer 2016 issue of
HealthFocus
, we will continue
this discussion with more details
about what programs can do
to successfully account for
social determinants.
References
1. Kindig, David A., MD, PhD.
What Is Population
Health?
Improving Population Health [blog]. University
of Wisconsin School of Medicine and
Public Health, Department of Population Health
Sciences. Web. Accessed January 12, 2016.
Available at
2. McGovern, Laura; Miller, George; and Hughes-Cromwick,
Paul.
Health Policy Brief: The Relative Contribution of
Multiple Determinants to Health Outcomes
. Health
Affairs, August 21, 2014.
3. McGinnis, Tricia; Crawford, Maia; and Somers,
Stephen A.
Issue Brief: A State Policy Framework
for Integrating Health and Social Services
.
The Commonwealth Fund, July 2014.
Available at
4.
National Prevention Strategy
. Office of the
Surgeon General. Department of Health and Human
Services (n.d.). Available at
Accessed January 8, 2016.
5. Department of Health and Human Services. Centers
for Medicare & Medicaid Services Innovation Center.
First-ever CMS Innovation Center Pilot Project to Test
Improving Patients’ Health by Addressing Their Social
Needs
[press release]. HHS.gov. Department of Health
and Human Services, January 2016. Available at
Accessed January 8, 2016.
6. Linkins, Karen W., PhD; Brya, Jennifer J., MA, MPP; and
Chandler, Daniel W., PhD.
Frequent Users of Health
Services Initiative: Final Evaluation Report
. Prepared
for the California Endowment and the California
HealthCare Foundation, August 2008.
7.
Winners of the 2014 Healthy Communities Achievement
Awards
. Healthy Communities Institute. Available at
Accessed
January 12, 2016.
