Social Determinants of Health Framework Supports Healthier Outcomes

By Tracy Wareing Evans, Executive Director, APHSA VIEWS 16

Social determinants of health (SDOH), “whole family” or “2 Gen” approaches, and population-level decision-making are key buzz words in the field today. The shared objective that each of these ideas embodies—whether you view it from the health care lens or human service perspective—is a desire for a more holistic approach that gets at underlying root causes and intervenes earlier, reducing more protracted social and health issues. 

While it is not a new idea that there is value in having programs that serve the same people talking, coordinating care, and working to solve problems earlier, applying a SDOH frame to these integrated efforts is a paradigm shift, especially when coupled with modern technology and business platforms. At their core, these movements are driven by the idea that cost-effective social interventions—not just medical ones—drive healthier outcomes for families and communities.


Both sectors understand that many health problems are prompted by poor nutrition, unhealthy living conditions, persistent social stressors, and other “determinants” that are more about our living environment and less about traditional medical models. On the health care side, new payment and service delivery reform mechanisms including, but not limited to, requirements for hospitals to conduct regular community assessments and reduce hospital readmissions, are driving the heightened use of population-based data to understand who is coming through the doors. In human services, knowledge of neuroscience, trauma-informed care, and behavioral economics is shaping more effective engagement strategies with clients before more government contact and longer-term involvement with families are needed. In both sectors, evidence-based program design is setting new standards and methods for how policy and practice is developed, and how outcomes are valued and measured. Focused efforts at all levels of government to share data and create interoperable systems undergird each of these trends.


In essence, the social determinants frame is helping us ask the same questions of health care patients as we do people seeking social service supports. If we can coordinate our work better across re-purposed programs and existing systems touching the same people, as well as provide the opportunity for every person to serve as a catalyst in his or her own care, then we have a better chance of creating pathways to sustainable, population-based health and well-being, The bottom line is we are not just talking about lowering health system costs but lowering system costs writ large—health and societal—by leveraging existing public investments in human services, housing, education, justice, and other areas to achieve better outcomes. Indeed, the SDOH frame may have just as much impact in bettering health outcomes as new medical breakthroughs.


A deeper look at the ways the health and human services fields are approaching social determinants and social interventions reveals that there is still a lot to learn about both eco-systems, including how best to connect them. Both systems are often painted unfairly, overly generalized, and misunderstood. One of our key partners and funders, the Kresge Foundation, is at the center of learning how to accelerate the connection of health and human services, with a focus on breaking down cultural silos, especially for financing, and identifying how to leverage social service networks—both public and community based—to maximize health and well-being outcomes.


One look at the recent literature suggests this is not a passing phase, but rather an intentional effort at a major cultural shift to reshape our service delivery models to drive better outcomes. Consider the following items released in just the last three months:


- The Mailman School of Public Health at Columbia University (Department of Health Policy and Management) and KPMG, LLP jointly produced a white paper examining the gap between social services and health, as the health system moves to a value-based purchasing model and seeks to leverage social interventions to reduce hospital readmissions and improve overall health outcomes.


- The Robert Wood Johnson Foundation continues to advocate for a “culture of health,” and recently released a “learning report” examining how social determinants of health data can improve health care and health. 


- The Laura and John Arnold Foundation announced its Moving the Needle Competition designed to encourage state and local jurisdictions to “adopt social interventions shown to produce large, sustained efforts on important life outcomes” and implement those interventions on a sizeable scale to determine whether they are replicable and can move the needle on important social problems.


I’m most struck by a reoccurring theme in the new reports that broadly paints the human service sector as unsophisticated, and, in some cases, untrustworthy. Social service providers are nearly always defined in the literature as “mom and pop” community-based organizations; as such, while they are seen as having the genuine ability to relate to people where they live and work, they are also seen as having very limited ability to manage a business or take on value-based contracting. The public-sector side of human services—if recognized at all—is depicted as unwieldy and incapable of delivering timely or effective services.


These are generalizations that give no credit to the long history or evolving infrastructures of the human service network in this country. It is the very services provided by this public-private network that holds so much potential for bending the health and social cost curve through more intentional preventive efforts, leveraging proven practices (especially existing strength and risk assessment tools), and tapping into existing structures and relationships. It is the public and nonprofit system of social services that already addresses at its core the SDOH—nutrition; affordable and safe housing; reduced risky behaviors; quality child care; supportive work environments, etc. There is legitimate concern that the health care sector will unwittingly reinvent the wheel by creating its own social serving apparatus, assessment tools, and delivery system within the existing health structure. There is much peril in doing this; it will only further divide and compartmentalize our service delivery, ultimately adding stressors and confusion to patients/consumers.


While it’s true that the two systems have some significant economic and cultural differences, we do a disservice to place broad generalizations on the sectors without attempting to understand the strengths of each, or to leverage the ways in which a social determinants framework puts a client/patient at the center. I am hopeful that the heightened attention that industry, philanthropy, and government is placing on social determinants and population-based health will enable us to more clearly map and understand the depth and strength of these ecosystems. At APHSA, through our members, partners, and collaborative centers, we pledge to continue to be a voice and advocate for how the social determinants of health can move us up the Human Services Value Curve.


You can read more about our specific efforts in the National Collaborative in our upcoming August issue of Policy & Practice.