Partnerships and Value

Connecting Clinical and Community Resources

September 28, 2017 1:00 pm

Social determinants of health are vital factors for healthcare leaders to keep in mind as they search for ways to improve health at the population level.

Leading a healthcare organization in a way that truly impacts the patient experience, outcomes, and costs requires a much broader perspective than simply addressing a patient’s clinical care. Real population health improvement hinges on understanding that, despite the best clinical treatments, health and recovery outcomes primarily occur outside of hospitals, health systems, doctors’ offices, and clinics.

In fact, as much as 60 percent of a patient’s health is driven by what happens after the patient leaves the hospital or clinic. 1 If healthcare leaders and organizations are to truly bend the outcomes curve, understanding the real-world challenges and barriers that patients face—and factoring those obstacles into care plans—is even more important to improving outcomes than is the actual medical care provided.

These real-world issues are the social determinants of health (SDOH) that impact a person’s ability to be and stay healthy. Examples of SDOH include access to transportation for therapy appointments, prescription pick-up, and grocery shopping; and having the financial means to pay for medications, the ability to read and understand medical jargon, and access to a strong social support network.

Effective Post-Acute Care

A return home from the hospital does not signal the end of a patient’s care, but simply the start of the next phase. Delivering effective post-acute care requires breaking down the silos that inhibit open communication among healthcare organizations; establishing connections and building relationships between providers, patients, and the community resources that patients need to maintain health and well-being; and, perhaps most importantly, actively listening to patients and getting them involved in their own care. 

Effective post-acute care helps patients stay connected and alerts the care team if their patient is struggling with the recovery plan. Consider, for example, an 85-year-old widower who returns home from the hospital after a heart attack. He lives alone, no longer drives, and could not afford the medications he was prescribed even if he had a way to pick them up (for that matter, he would also struggle to read the fine print and understand the instructions). His children live in another city, and since his wife’s death, he has stopped socializing at church and with neighbors, leaving him with virtually no social support. 

His care plan may be clinically appropriate, but how effective can it be?

To fully understand the barriers a person may face, providers are becoming more adept at identifying and solving SDOH. Probing deeper allows providers to uncover social needs and potential gaps in care. These obstacles can be addressed proactively through the use of supportive networks and community resources.

A cardiology group at a regional hospital in the Southeast was aware that its patients were experiencing higher-than-acceptable rates of readmissions and preventable visits to the emergency department (ED). The hospital had data on each patient and on each department within the hospital but was not making the best use of the data. For example, the care team’s communication processes did not support patients as they moved from an intensive care bed to a general bed and then on to discharge to home. Important details were either missed or delayed, leading to an inefficient use of time and resources.

Administrators decided to implement a system that allowed every provider to track the progress of a patient and enter information that could be easily accessed and disclosed, including social and environmental obstacles and how the patient best relates to caregivers. Patients now receive follow-up calls within 48 hours of returning home, and skilled professionals empathetically ask open-ended questions to encourage a conversation that will help redirect potential risks for relapse and preventable returns to the ED.

Expanding the Continuum

Forming alliances, collaborating with community resources and support networks, and using real-time data to identify and solve SDOH is not limited to formal healthcare settings. We are seeing this effort expand into all areas of health, including the part that determines 60 percent of our health outcomes—i.e., time spent outside healthcare settings.

Providers are collaborating with community-based organizations (CBOs) that are dedicated to working with individuals and families who need food, housing, transportation, and other resources to improve their health. Providers must be prepared to contact CBOs and ensure that their connections are accurate, up-to-date, and the right fit for their patient’s needs. Implementing a system that ensures that CBOs and patients follow through on referrals is a crucial step.

In fact, community partners increasingly are taking the lead in efforts to improve the health of their communities. For example, in the San Antonio area, a need to increase the service capacity for individuals and families experiencing autism spurred community and philanthropic organizations to help form Austism Lifeline Links. The organization provides solutions, resources, and a community network for these previously underserved individuals and famililes. 

Autism Lifeline Links effectively combined management styles of its various partners, including the Children’s Hospital of San Antonio, to form a valuable resource that shares information with providers, patients, and families using an HIPAA-compliant, confidential approach. The expansive network has a single point of entry, simplifying what is often an overwhelming process for families seeking solutions. Care coordinators respond within 24 hours to initial requests, addressing needs, providing information, and opening the doors to multiple community partners. This streamlined process has helped hundreds of individuals and families make informed decisions while maintaining a continuity of care.

As we continue our transition to value-based care, programs that address SDOH will strengthen communities and family networks, which in turn will lead to better outcomes and fewer readmissions following hospital-based procedures.

Organizations that take these steps are reaping the benefits of improved clinical and financial outcomes for patients. Ultimately, they are achieving the true definition of value-based care.

Jamo Rubin, MD, is founder and CEO, TAVHealth, San Antonio, and chairman, the Texas Biomedical Research Institute.


1. Bradley, E.H., Taylor L.A., Coyle C.E., et al., “ Leveraging the Social Determinants of Health: What Works? Yale Global Health Leadership Institute, prepared for Blue Cross Blue Shield of Massachusetts Foundation, June 2015.


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