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Research is mixed on the efficacy and feasibility of programs aimed at addressing patients' social determinants of health (SDOH) to improve outcomes and lower overall health care costs. Writing for Kaiser Health News/Modern Healthcare, Phil Galewitz explores how health systems are navigating this lack of clarity—and trying to invest in the programs that actually work.
How to advance equity for your workforce, patients, and community
Background
According to Galewitz, researchers have known for "decades" that social issues—including unreliable housing or food access—can undermine patients' health. However, it wasn't until 2010, when the Affordable Care Act became law and increased the shift from fee-for-service to value-based payment, that providers had a financial stake in addressing social determinants of health. Since then, SDOH programs have been taking off among hospitals, health systems, and public and private insurers.
For instance, a 2020 study found that more than 50% of states are establishing or expanding Medicaid programs that address SDOH. And while most of those interventions are not "intense," Galewitz writes, some are significant. North Carolina, for example, is investing $650 million over the course of five years to assess the benefits of helping Medicaid beneficiaries secure housing, food, and transportation. And California is redesigning its Medicaid program to substantially increase the social services it provides for beneficiaries.
Not all SDOH programs are effective
However, the research on the efficacy and feasibility of such efforts is limited. Most of these programs are new and haven’t yet produced a noticeable impact, Galewitz writes. And many of the studies that have produced results have had mixed findings. As a result, hospitals and health systems struggle to decide what programs to invest in.
"We are probably at a peak of inflated expectations, and it is incumbent on us to find the innovations that really work," said Laura Gottlieb, director of the University of California-San Francisco Social Interventions Research and Evaluation Network. "Yes, there's a lot of hype, and not all of these interventions will have staying power."
For instance, the University of Pennsylvania Health System several years ago established a program giving one-time rides to low-income patients for free in the hopes of reducing their no-show rate for primary care appointments, which at the time was 36%.
However, a 2018 study on the initiative found it didn't have "any effect," said Krisda Chaiyachati, a researcher at Penn who helmed the study. According to Galewitz, a subsequent study found that patients were not using the complimentary ride because they either wanted to save it for more pressing appointments or because they preferred their routine modes of transportation.
Successful programs often struggle to expand
Another challenge for SDOH programs, Galewitz writes, is that the inventions which appear to work generally serve only a limited number of patients and can be difficult to fund.
For example, Temple University Health System in 2020 established a two-year program to help 25 Medicaid patients who were experiencing homelessness and frequently used the health system's ED access secure housing and other social services. Qualifying participants in the program had to have used the ED at least four times in the prior year and incurred a minimum of $10,000 in medical claims during that time frame.
The outcomes of the program were positive, Galewitz writes. Within in the first five months of being housed, participants' average number of ED visits declined 75% and their inpatient hospital admissions dropped by 79%. Meanwhile, their visits to outpatient services increased by 50%, suggesting the participants were going to more appropriate and cost-effective care settings.
Although the program requires a significant investment of about $700,000 for one year—$28,000 per person—Temple officials say it could help save money over time by reducing the number of costly hospital visits. However, if Temple would like to provide such services for more patients, it could require "tens of millions of dollars more per year," Galewitz reports.
A similar program launched at two Duke University clinics in 2016 successfully reduced ED visits for participants, in part by arranging housing for them. However, the program has served just 45 patients since 2016. Duke has been unable to expand the program because organizers have had difficulty securing more financing without additional data showing health care cost savings.
A 'new and emerging field'
Although the evidence supporting these SDOH programs is incomplete, experts say the current status quo—with Americans generally presenting with poorer health than their peers in other industrialized nations—isn't working.
"At some point, we keep paying more and more [for health care] … and people keep getting less and less," Elena Marks, CEO of Episcopal Health Foundation, said. "So, let's go look for some other solutions."
Marks added that this "is a new and emerging field," acknowledging that while the "evidence is weak for some" and "mixed for some," it is also "strong for a few areas"—and those areas merit continued investment.
But according to Galewitz, those investments remain difficult to fund. "We are trying to find the magic sauce to keep this program running," Patrick Vulgamore, project manager for Temple's Center for Population Health, said (Galewitz, Kaiser Health News/Modern Healthcare, 6/22).
When the research is lacking, here is where to prioritize your limited resources for SDOH interventions
By Darby Sullivan, consultant
The Kaiser Health News/Modern Healthcare article brings up one of the biggest roadblocks for organizations and agencies interested in addressing the social determinants of health. But I'd disagree with any implication that social needs interventions inherently don't work. The bigger problem is not that the research proves these programs are ineffective, but that there hasn't been nearly enough rigorous research conducted on these emerging models. Research on the efficacy of social needs interventions is still nascent, and in the absence of good data, most organizations are left to design their own programs and wait to see if it "works"—which is far from the evidence-based ideal we're used to in health care.
That said, the quality of the emergent evidence base is important to understand when interpreting the broader implications of existing research. There are a few more nuances I would add to Galewitz's take about why we still don't have the robust evidence base we want on social determinants of health interventions.
- The selection process for what to study—and what not to study—often lacks sufficient rigor. Since addressing social needs is still widely seen as a community benefit or charity activity, we've noticed that efforts are sometimes directed toward passion projects rather than community designated priorities—areas with the potential for the largest impact.
- The design of the study itself is determined in relative isolation from the target population. That's how organizations end up designing a transportation service to improve no show rates, for example, when the problem is actually rooted in mistrust of the health care system. The result is wasted resources and doubt casted on the value of transportation interventions.
- Researchers design short-term patient-facing solutions to address long-term structural problems. Proving the immediate impact on cost and clinical outcomes are important and can be a powerful incentive for organizations to invest in these programs. But if efforts stop there, we won't see any impact on the community conditions and their root causes (structural racism and intergenerational poverty) that lead to high-cost high-need patients in the first place.
- Ultimately, the social determinants of health are so inextricably linked with one another that it's tough to "solve" one unmet need—and measure cost or clinical improvement—without addressing them all at once. For example, a pilot that connects affordable food to families in need will have limited impact if the family also faces housing insecurity. Successful models need to meet the holistic needs of individuals, but that makes it challenging to parse out which intervention has what degree of impact on outcomes.
While there is much that remains unknown in the SDOH space, what is no longer under debate is the impact of social needs on health outcomes. So even though it's essential for the industry to dedicate more time and funding to create high-quality interventions, there's no question that we're heading in the right direction.
Practically speaking, though, organizations across the industry need to figure out how they'll take a rigorous and standardized approach to sustaining effective models. That starts with scoping the challenges and strengths in the communities they serve by collecting and analyzing comprehensive quantitative data and qualitative community input. Importantly, significant community collaboration is a non-negotiable for designing an intervention that will actually meet the root of non-clinical needs. From there, we recommend leaders consider the following to prioritize where to direct their limited resources:
- Synergy with broader organizational goals, which sets up a business case that aligns to strategic priorities;
- Feasibility to inflect need over time, which improves the likelihood of measuring a return on investment;
- Ability to allocate internal resources, which guarantees that the organization can dedicate support to sustain the targeted intervention; and
- Resources for interventions already exist, which allows for economies of scale
To review the existing academic literature for social needs interventions, check out the Care Delivery Innovation Reference Guide. For more on how to select and design SDOH programs that actually work, review the 10 Tools for Prioritizing Community Health Interventions.
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