Social, economic and environmental factors that influence health are referred to as social determinants of health (SDOH) and recently there has been increased recognition of the importance of these factors on overall health and well being. They include conditions in which children, youth and families are born, grow up, live and work, as well as the quality and accessibility of health care (Shern et al. 2011). The U.S. Department of Health and Human Services developed the framework above to reflect five key areas of social determinants of health. Underlying factors for each social determinant of health include: (Healthy People 2020)
- Economic Stability – employment, food insecurity, housing instability and poverty
- Education – early childhood education and development, enrollment in higher education, high school graduation and language and literacy
- Social and Community Context – civic participation, discrimination, incarceration and social cohesion
- Health and Health Care – access to health care, access to primary care and health literacy
- Neighborhood and Built Environment – access to foods that support healthy eating patterns, crime and violence, environmental conditions and quality of housing
While access to quality, affordable health care is important, individual behaviors – such as smoking, diet and exercise – are the greatest predictors of premature death. Likewise, the importance of social and environmental factors is significant (Kaiser Family Foundation). In fact, research led by Dr. Sandro Galea, Dean of the Boston University School of Public Health, concludes that the number of deaths attributable to social factors in the U.S. is comparable to those attributed to pathophysiological and behavioral reasons:
For example, the number of deaths… calculated as attributable to low education is comparable to the number caused by acute myocardial infarction (192,898), a subset of heart disease, which was the leading cause of death in the United States in 2000. The number of deaths attributable to racial segregation is comparable to the number from cerebrovascular disease (167,661), the third leading cause of death in 2000, and the number attributable to low social support is comparable to deaths from lung cancer (155,521). (Galea et al. 2010)
Mental health – as part of overall health -- and many common mental health conditions are shaped to a great extent by social determinants. According to the World Health Organization:
Social inequalities are associated with increased risk of many mental health conditions. Taking action to improve the conditions of daily life from before birth, during early childhood, at school age, during family building and working ages, and at older ages provides opportunities both to improve population mental health and to reduce the risk of those mental conditions that are associated with social inequalities… Scientific consensus is considerable that giving every child the best possible start will generate the greatest societal and mental health benefits. (World Health Organization)
In the area of mental health, the impact of social determinants is also viewed from a life-course perspective, meaning one that looks at how risk exposures in the formative stages of life can affect mental well-being or predisposition to mental health conditions years later (World Health Organization). For mental health, social determinants must be addressed not only for their immediate detrimental impacts, but also in terms of prevention initiatives to reduce future risks of mental health conditions.
Fortunately, state and federal health reform efforts are placing greater emphasis on social determinants of health, both to improve the health of patient populations and to reduce health care spending. The Health Policy Commission’s Accountable Care Organization (ACO) certification standards include requirements related to social determinants of health. Specifically, ACOs are required to: (Massachusetts Health Policy Commission)
- Population health management - The ACO routinely stratifies its entire patient population and uses the results to implement programs targeted at improving health outcomes for its highest need patients. At least one program addresses behavioral health and at least one program addresses social determinants of health to reduce health disparities within the ACO population.
- Assesses needs and preferences of patient population - How does the ACO assess the needs and preferences of its patient population with regard to race, ethnicity, language, culture, literacy, gender identity, sexual orientation, income, housing status, food insecurity history, and other characteristics? How does the ACO use this information to inform its operations and care delivery to patients?
- Supports community-based health programs - How does the ACO use the information gathered in the criterion above to develop and support community-based policies and programs aimed at addressing social determinants of health to reduce health disparities within the ACO population?
The MassHealth 1115 Demonstration similarly places significant focus on the integration of health-related social services. Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) are required to partner with behavioral health and long-term services and supports Community Partners (CPs). CPs are responsible for care management and care coordination, as well as referral to community and social supports. The Demonstration also includes a new Delivery System Reform Incentive Program (DSRIP); sixty-percent of DSRIP funds are earmarked for ACOs, including funding for flexible services to address health-related social needs. Flexible services can be used across multiple domains, including services to maintain a safe and healthy living environmental, physical activity and nutrition, and supports for those who have experienced violence. (Commonwealth Medicine)
Likewise, the Centers for Medicare and Medicaid Services (CMS) worked with a panel of national experts to develop a 10-question screening tool to identify patients’ social service needs. The sceening tool covers the domains of housing instability, food insecurity, transportation challenges, utility assistance needs, and interpersonal safety. “Clinicians and their staff can use this short tool across a spectrum of ages, backgrounds, and settings, and it is streamlined enough to be incorporated into busy clinical workflows. Just like with clinical assessment tools, results from this screening tool can be used to inform a patient’s treatment plan as well as make referrals to community services.” (Billioux et al. 2017)