Social Determinants of Health

Expanding the Continuum of Care

September 20, 2017 12:10 pm

If we hope to rein in the burgeoning epidemic of chronic conditions, we’ll have to venture further upstream.

More than 190 million Americans, or about 59 percent of the population, are affected by at least one chronic condition. Over the next 15 years, that number is projected to grow to 80 percent. a I’ve written in this space before about the impact of chronic conditions on healthcare spending. Over 90 percent of total spending in traditional Medicare is for the care of patients who have more than one chronic condition, including substance use and mental health disorders.

Going Beyond Management

Clearly, better management of chronic conditions is essential if we hope to make a dent in the rate of healthcare cost growth. But to turn this ship around, we will have to go beyond management to prevention. That’s where social determinants of health (SDOH) come in.

Healthy People 2020, a federal initiative that set 10-year goals for improving the health of all Americans, defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

These key determinants are categorized under economic stability, education, social and community contexts, and neighborhoods and built environments, as well as the healthcare system. Witnessing the effects of disparities in SDOH has led some physicians to say that a person’s zip code can affect health more than their genetic code. b

It’s All Connected

Consider the impact of just one SDOH: food insecurity (which falls under the economic stability category). Food insecurity has been linked to 10 major chronic conditions identified by the Centers for Disease Control and Prevention as particularly worthy of research because of their prevalence, cost, morbidity, and preventability.3 Among these are hypertension, heart disease, cancer, asthma, and diabetes. In some cases, food-security status is more strongly predictive of chronic illness than even income.

SDOH assessment tools that address food insecurity are available. For example, as part of its Accountable Health Communities Model, the Centers for Medicare & Medicaid Services developed a screening tool to identify patient needs in five areas, including food insecurity, that can be addressed through community services. The tool is designed to be incorporated into busy clinical workflows, and results can inform treatment plans and trigger referrals to community services.

What Next?

Many provider system executives argue that tackling SDOH goes far beyond the traditional boundaries of acute care and the healthcare system. In a population health management framework, however, it’s clear that we must figure out how to take this on: Addressing SDOH will drive value and is a logical extension of the continuum of care. Still, in a fee-for-service environment, managing to SDOH is a lot to ask.

The question comes down to what role we play, as finance leaders, in reducing the cost of care. In the long run, can we afford to overlook what might be the single biggest cost driver? Is it OK to conclude that SDOH are someone else’s responsibility, and end up with a healthcare system that no one can afford?

Alternatively, can we construct payment models in which stakeholders truly share the risk and responsibility of managing to SDOH, and align incentives accordingly? I would argue that’s a duty we all have.

For SDOH assessments to become part of a medical history and physical, payment and time constraints must be addressed. For the assessment results to be actionable, linkages with community agencies must be established or strengthened. And for lasting benefit to accrue to the patient, the organization, and the healthcare industry, consensus on metrics, longitudinal tracking, reporting, and assessment processes must be achieved.

The first step is to take ownership of the issue. That’s the biggest hurdle. Once there is a will to find solutions, solutions will be found.


a. “Overview of New Research on the Burden of Chronic Diseases in the Next 15 Years,” Partnership to Fight Chronic Disease, 2017.

b. Foden-Vencil, K., “Your Zip Code Might Be as Important to Your Health as Your Genetic Code,” National Public Radio, Aug. 4, 2017. 

c. Gregory, C., and Coleman-Jensen, A., “Food Insecurity, Chronic Disease, and Health Among Working-Age Adults,” U.S. Department of Agriculture, July 2017.


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