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Home > Healthcare Trends
Social Determinants and Population Health: Redesigning Care Management to Bridge Clinical and Non-Medical Services
Social Determinants and Population Health: Redesigning Care Management to Bridge Clinical and Non-Medical Services
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Although nearly three-fourths of health outcomes are determined by social determinants, few clinicians can ably identify those patients facing challenges related to social and environmental conditions or other experiences that directly impact health and health status. 

In Social Determinants and Population Health: Redesigning Care Management to Bridge Clinical and Non-Medical Services, care teams will learn that by asking patients the right questions and listening carefully to their responses, they can begin to identify and address social determinants, dramatically impacting patient outcomes as well as their own financial success under value-based care.

Via a set of patient scenarios, Dr. Randall Williams, chief executive officer, Pharos Innovations, walks healthcare organizations through five key social determinants, and then suggests multiple approaches for care teams to begin to address social determinants in population health.

According to a December 2016 ASPE report to Congress on Social Risk Factors and Performance Under Medicare's Value-Based Purchasing Programs, there is growing evidence that social risk factors—income, education, race and ethnicity, employment, community resources, and social support—play a major role in health, and that significant gaps remain in health and in life expectancy based on income, race, ethnicity, and community environment.

In this 28-page report, Dr. Williams covers the following areas:

  • Defining the social determinants challenge, including the readiness of healthcare and social services to effectively integrate to improve clinical and social outcomes;
  • Real world examples of addressing social determinants of health through patient engagement;
  • Balancing technology-enhanced care models with the challenges and limitations of individuals with chronic illness;
  • Relationship of health literacy to access to care;
  • The cultural contexts of healthcare decision-making and suggestions for bridging the gap between the culture of medicine and the patient’s culture;
  • Care delivery approaches for recognizing and reacting to social determinants of health;
  • Motivations and benefits of addressing social risk factors for accountable care organizations (ACOs) and other organizations;
  • Examples and options for assessing individuals for social determinants as part of an overall care delivery redesign challenge;
and much more.

Table of Contents

  • Social Determinants and Population Health: Moving Beyond Clinical Data in a Value-Based Healthcare System
    • Defining the Social Determinants Challenge
    • Specifics of Social Determinants
    • Social Determinant Example 1: Social Isolation
    • Social Determinant Example 2: Technology
    • Social Determinant Example 3: Access to Care and Health Literacy
    • Social Determinant Example 4: Living Situation and Environment
    • Social Determinant Example 5: Economical and Cultural Context
    • Addressing SDH Through Integration
    • Addressing Social Determinants at an Organizational Level
    • Assessing Level of SDH Integration
    • SDH Case Study 1: Engaging ACO Patients in Technology-Enabled Surveys
    • SDH Case Study 2: Linking Community Resources to Clinical Resources
  • Q&A: Ask the Expert
    • Engaging the Physician Office in Social Determinants
    • Social Determinant Assessment Tools
    • Funding Social Determinant Assessments
    • Patient Honesty in Divulging Social Determinants
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: January 2017
Number of Pages: 28
ISBN 10: 1-943542-42-2 (Print version); 1-943542-43-0 (PDF version)
ISBN 13: 978-1-943542-42-0 (Print version); 978-1-943542-43-7 (PDF version)
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