Social Determinants of … HELP!

Perhaps you have more questions than answers about the Social Determinants of Health, such as:

  • Why are social determinants important?
  • Should I look at the community at large or individuals?
  • Where do I start?
  • How do I know if my patient or member population has unmet needs?
  • What is a Z Code?
  • How much money did an ACO save by targeting malnutrition?
  • Can programs targeting homelessness really save a provider money?
  • Is there a bigger return on investment for social service navigation than there is for just making a referral?
  • What are providers and payors doing now? I need real life examples and resources.

We can help!


Regulators, providers and payors are increasingly focused on socioeconomic wellness factors in addition to clinical care. But why?

Clinical care accounts for only 20% of health status and outcomes. Another 40% includes health behaviors (30%) and physical environment (10%).The remaining 40% is attributable to social and economic factors including, but not limited to, food insecurity, housing, transportation, utilities, interpersonal violence, language barriers, education and income. Better health and reduced cost of care is achievable by addressing gaps in these areas of basic life needs.


Social Determinants v Social Needs
The Department of Health and Human Services (HHS) defines the social determinants of health as the “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.”

There are social determinants and there are social needs. Both are important. Think about social determinants as impacting the community at large and social needs as having a more individual impact. I like this metaphor, borrowed from de Beaumont Foundation and Trust for America’s Health, of a stream, with upstream factors bringing downstream effects.

Social determinants are upstream community conditions. Social needs are the midstream, individual needs. Clinical care is downstream. Focusing our social intervention efforts upstream, at the community level, has the effect of building a dam, lessening social needs midstream and demand for clinical care downstream. Let’s use a quick example. Suppose you and your neighbors live in a food desert, a community without a grocery store. Food desert might be the upstream community condition or social determinant. The individual social need then would be food. Lack of food, particularly nutritional food can cause malnutrition which may require medical intervention downstream.

Research shows a strong connection between food security and health. People with food insecurity are more likely to report poor health and to have multiple chronic conditions.

A 2017 study in JAMA Internal Medicine found that addressing food insecurity was associated with significantly lower healthcare expenditures. After adjusting for factors like age, gender, race/ethnicity, education, comorbidities, and geographic location, the study found that low-income adults who participated in the Supplemental Nutrition Assistance Program (SNAP) had healthcare expenditures that were $1409 lower per year compared with non-participants.

Housing is the largest expense for most households, consuming one-third, one-half, or more of monthly income. Safe, stable, and decent housing is central to ensuring stability and an important driver of health outcomes.

Research published by Robert Collinson and Davin Reed in December 2018 titled The Effects of Evictions on Low-Income Households shares the effects of eviction on adult physical and mental health. Their investigation found that evictions worsen health, particularly mental health, and increase emergency room utilization.


Identifying Need
Identifying need will be different for social determinants of health than for social needs.

Social Determinants

Community Assessments are one way of identifying social needs at a community level, and they aren’t limited to hospitals. According to the Centers for Disease Control and Prevention,

“A community health assessment (sometimes called a CHA), also known as community health needs assessment (sometimes called a CHNA), refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis.”

Social Needs
Social needs can be identified through patient assessments, ICD-10-CM Z codes, expanding your electronic health record to a comprehensive health record, the use of technology, and more.

  • Studies have found that most providers don’t ask their patients about social needs; however, most patients want doctors to ask them about access to meals and safe and stable housing.
  • ICD-10 Z codes are a subset of ICD-10-CM codes, used as reason codes, to capture “factors that influence health status and contact with health services.”
  • According to Epic Systems CEO Judy Faulkner, a comprehensive health record includes information not currently in an electronic health record, care provided outside the hospital, and more data types, notably social determinants.
  • Technology is the enabler of data interoperability. Tools like artificial intelligence, natural language processing, patient matching and unique patient identifiers, telemedicine, remote patient monitoring and self-care, records management and algorithms can facilitate the ability to engage and track at-risk individuals across providers, social service agencies, community-based organizations and others.
  • Social Service+, a Centauri Health Solutions offering, is a social service referral and support program that assesses dual-eligible health plan members individual needs on behalf of their Medicare Advantage plan, then works to meet them before making a warm transfer back to the health plan.


To be effective, a social health strategy must embrace a diverse array of stakeholders including health systems, public health, community-based providers, public and private payers, social services, researchers, vendors, standards organizations, and consumer advocates.

Targeting Malnutrition

Chicago-based Advocate Health Care is a Chicago-based Accountable Care Organization (ACO) with four hospitals. They launched two initiatives targeting malnutrition. The ACO started by screening all patients at admission for malnutrition risk. Patients with elevated risk scores received an oral nutritional supplement within two days of admission. High-risk patients were recipients of nutrition education, post-discharge instructions, follow-up calls, and coupons for retail oral national supplements, all part of an enhanced nutrition care program. Within six months, Advocate Health Care reduced healthcare costs by $3,800 per patient, resulting in $4.8 million in total savings. The ACO also saw hospital readmission rates drop among patients at risk for malnutrition.

Housing the Homeless
The University of Illinois Hospital at Chicago reinvested $250,000 in Better Health Through Housing.

Homeless patients overuse the emergency department, suffer from chronic illness, and negatively impact a hospital’s community. Using a combination of housing insecurity severity and chronic disease comorbidities, the hospital determined who should participate in the program. The hospital contributes about $1,000 per patient for housing support, a net financial gain of about $2,000 when compared to the amount hospitals usually spend on chronically homeless emergency department stays. Average per patient monthly costs dropped from $5,879 to $4,785 each month.

Provider Incentives
Priority Health in Michigan will pilot new provider incentives starting January 1, 2021. In exchange for using an approved tool to screen Priority Health Medicare and Medicaid members, completing a survey attestation, and submitting ICD-10-CM Z codes on claims during screening, Patient-Centered Medical Home providers will receive increased reimbursement.

Assistance Line
WellCare Health Plans and the University of South Florida College of Public Health, Tampa conducted a study, proving that something as simple as a toll-free assistance line can produce measurable results on healthcare costs such as physician office visits and emergency department use. The study involved WellCare Medicaid and Medicare Advantage members who accessed WellCare’s Community Assistance Line. The study compared the 2,718 participants who had their identified social need met versus those that did not. Savings per person were calculated to be more than $2,400 annually for those that were successfully connected to social services.

Social Service+
Centauri’s Social Service+ solution utilizes a social determinants of health (SDoH) assessment model to conduct an assessment, identify local resources to solve problems, provide those resources to Medicare Advantage plan members, assist them in connecting with those local services and following up with them to ensure they have received the services needed. Based on an individual assessment, Centauri frequently refers members in need to Food Pantries, Home Delivered Meals, Senior Case Management Agencies, Subsidized Transportation agencies, etc.


What have we learned? There is not a one-size-fits-all answer to social determinants or social needs! First, you should identify the need. Second, identify your focus. Is it social determinants, social needs, or both? Third, determine your strategy. Get help if you need it. There are organizations that offer solutions, like Centauri’s Social Service+. Fourth, implement your strategy, monitor, follow-up, and measure your results.


Shanna Hanson, FHFMA, ACB
Manager, Business Knowledge
Centauri Health Solutions, Inc.