Service line leaders may have multiple ways to address social determinants of health. In many cases, service line leaders may be able to join system-wide efforts that are already underway or partner with another service line. In certain circumstances, a service-line specific approach may be necessary.

Support system-level initiatives

Traditionally, SDOH has not been a primary focus for service line leaders. Many institutions spearhead and fund SDOH interventions at the system level; some even have entire departments designated for such initiatives, such as population health. For service line leaders who are part of such systems, the best and most effective strategy may be to join efforts already underway so that they can advocate for their patient population’s specific needs.

To ensure that their patients’ needs are being met by system-level strategies, service line leaders should advocate to have a seat at the table where these initiatives are planned. Similarly, service line administrators can invite the leaders of population health or health equity initiatives to their own internal strategy and operational meetings. Bidirectional communication and collaboration will help expand your role as an advocate and champion for your patients in system-wide SDOH programming. For example, a CV leader can make sure their health system's centralized food pantry program meets the needs of their patients by making sure the food options provided are heart healthy.

Partner with other service lines

If your system doesn't have a centralized population health department or other entity responsible for health equity initiatives, cross-service line partnerships can decrease the burden of implementing SDOH interventions. Service lines with similar SDOH goals can reach them efficiently through teamwork. For instance, the pulmonology and oncology service lines can launch regularly scheduled health fairs for a community in an outlying geography to facilitate access to lung cancer screening. Additionally, if your service line lacks an asset that another service line has, like connections with local groups that can advertise the health fair, sharing resources enables the execution of successful SDOH initiatives.

Take a service line-specific approach

There are some situations or circumstances where it may be necessary for you to tackle SDOH alone. We’ve provided a sample list of situations that may warrant a service line-specific approach.

Indicators for a service line-specific approach

1 There are neither central bodies that run SDOH initiatives nor institution-wide SDOH programs that directly address the needs of your patient populations. There is no centralized population health department or entity that organizes system-wide SDOH initiatives and no other SLs are interested in partnering on SDOH initiatives.

2 The impacts of SDOH have financial and quality implications unique to your service line. Service line leaders are often responsible for unfavorable financial or quality outcomes. Focusing on patients’ non-clinical needs such as nutrition, transportation, and social support can decrease events like avoidable readmissions or ED overutilization.

3 You are seeking an accreditation or designation that mandates you to address SDOH. Receiving a certification for your program often comes with stipulations that may require a focus on SDOH with initiatives specific to your patient population. For instance, National Cancer Institute-designated cancer centers must provide evidence-based services tailored to the community.

4 Service line-specific funding is available to back SDOH initiatives. Service lines that have additional funding from their institutions or outside organizations like grants can improve care for their patient population. Discretionary funds for the cardiovascular service line, for example, can finance the local food bank to provide healthy, nutritious food options for high-risk heart disease patients.

5 Your service line has a strong community partnership that can be leveraged into a SDOH program. Preexisting relationships with community organizations can be leveraged to implement a SDOH initiative. For example, a partnership originally made between an obstetrics-gynecology service and a church to provide health education classes can also be leveraged to provide shelter and care to homeless or vulnerable women.

A growing number of providers now screen for social needs and navigate patients to non-clinical services. While this is a good start, current initiatives are often reactive and focus narrowly on individual patients. Service lines should also address SDOH at a population level. To do this, To do this, service lines need to build out their data, staffing, and funding infrastructure.

Collect and analyze data to understand patient needs

Basic screening for non-clinical needs is common. But service lines need to go one step further by collecting demographic information that can help leaders analyze community need and formulate interventions. Hardwire the collection of race, ethnicity, gender identity, sexual orientation, age, and language (REGAL) data across top clinical morbidities. No matter what data gets collected, examine it for trends or correlations between patient demographics, questionnaire responses, and clinical outcomes.

To help translate the data into action, consider using a dashboard to visualize findings and communicate identified disparities to internal and external stakeholders. Leverage the dashboard to create organizational- and community-wide awareness of specific SDOH that could lead to poor outcomes.

Data collection and analysis should be an on-going process, even after programs and interventions are formulated and implemented. For example, if a dedicated Spanish language stroke clinic is established to remove language barriers as a driver of poor care outcomes, continue collecting and tracking data on utilization, readmissions and care plan adherence to gauge the clinic’s performance. Survey targeted patient populations on the effectiveness of the program. Any approach should be flexible enough to be adjusted according to follow up analyses to ensure that you are actively and continuously meeting patient needs.

Train providers and staff about how to address SDOH

Maintain and foster SDOH content knowledge by keeping staff educated and engaged. Many providers stop at diversity and inclusion trainings as part of staff orientation. Get ahead of the curve by providing annual trainings for leaders and maintaining an open dialogue on how your team can better address the non-clinical factors that affect outcomes, as well as how they can actively remove bias from the daily care they provide.

Fund staff to support SDOH strategy

Promoting sustainable improvements in your service line can be as simple as strategically allocating dollars to investments that directly impact your patient populations. This can mean investing in staff that improve patient management, such as case managers, social workers, and community health workers. It can also mean hiring diverse staff who can bring more points of view use their shared experience with their patients, to more accurately solve their clinical needs.

Proactively identify funding sources for SDOH initiatives

Without proper funding, SDOH initiatives will struggle. Set yourself up for success by utilizing any available sources. Work with your philanthropy team to determine if fundraising or donor options are available. Consult your operations team to carve out a piece of the budget to health equity initiatives. Allocate time or staff to apply for grants from outside organizations.

Service line leaders do not need to act alone. Indeed, they cannot act alone if they hope to be successful. After all, many SDOH-related consequences can only be confronted outside of the health system. Provide more support to patients in their everyday lives by working with community partners.

Working with the community and partnering with outside organizations offers opportunities for community-based interventions that may result in early detection, enhanced care plan adherence, and preventative care and education. There are several ways service line leaders can work with community organizations.

Select ways your service line can work with community partners