Blog 4 – Social Determinates of Health and Community Resources

Community engagement is one of the six pillars of the Center for Disease Control & Prevention’s work to address Social Determinants of Health (SDoH). This pillar involves fostering meaningful, sustained relationships with community groups and people with lived experiences to understand and develop solutions to help address SDoH and improve health. Community engagement can help build trust, empower communities, and promote social justice. 

What Is CDC Doing to Address Social Determinants of Health? | About | CDC

As healthcare systems implement social determinants of health (SDoH) screenings into their electronic health records (EHR) and begin screening their patients, they start to have a better understanding of the unmet health needs of their community. Linking patients to appropriate resources can begin helping them achieve optimal well-being. What are healthcare organizations to do with the information obtained by the SDoH screening? It can be as basic as providing the patients with a list of resources as a first step, however, taking a more active role in providing resources and working alongside patients to ensure they have accessed the resources successfully will create a closed-loop approach and make a larger impact on the patient.

Healthcare organizations can effectively collaborate with community resources to address social determinants of health while considering a range of critical factors. Key elements to consider:

• Collaborative Partnerships: Building strong, collaborative partnerships with local community-based organizations and social service agencies is essential. These partnerships expand the range of available resources and enhance support for patients.
• Cultural Competence: Recognizing and respecting cultural diversity is crucial. Understanding the cultural norms, beliefs, and practices of the communities served allows organizations to tailor their approaches to better address specific SDoH needs.
• Patient Navigation Services: Patient navigators play a pivotal role in guiding individuals through complex healthcare and social service systems. They can help patients access the resources they need effectively.
• Sustainability and Scalability: Ensuring the long-term sustainability and scalability of programs that integrate SDoH into healthcare is vital. Sustainable models guarantee that efforts to address SDoH remain effective over time.
• Data Sharing and Privacy: Managing data sharing and patient privacy in compliance with health regulations is critical. Securely handling patient information and adhering to privacy laws like HIPAA is essential when working with community resources.

Organizations can assist patients with their SDoH needs by utilizing/hiring community health workers (CHWs). Community health workers are frontline health workers who have a deep understanding of the communities they serve and can be patient advocates and guides through the available community resources available to them. They are often representative of the populations they serve, with lived experiences that help them make connections that the clinical workforce may not. CHWs can identify and address the barriers to care, empower and motivate patients to take charge of their own health and well-being, and connect patients to health and social services within their community that meet their needs such as food, housing, transportation, etc. Community health workers have a unique and valuable role in addressing the SDoH and promoting health equity. It is important to recognize and support the sustainability of such programs that can effectively serve the needs of vulnerable populations within organizations.

Technology not only can help organizations create their strategy around implementing SDOH into their healthcare systems, and provide insight into their patient’s social needs but it can also help link patients screened to resources available to them. Websites that are easily shared with patients like findhelp.org by findhelp - Search and Connect to Social Care can assist healthcare organizations and patients find resources available to them. Often these websites are integrated within the EHR and can be included in patient’s discharge/after visit instructions or patient portal. Linking patients electronically to resources through health information exchanges (HIEs) or other third-party platforms that connect the electronic health record with community-based organizations that provide services addressing their specific needs. Some platforms, like United Us© and Aunt Bertha© allow the providers and community-based organizations to track referrals and outcomes of the patients, creating a feedback loop that improves care coordination and quality.

No matter which approach an organization chooses, any step toward helping to connect patients to community resources will be a step closer to improved outcomes for patients.  While gathering SDoH data on patients can help direct larger program efforts, ensuring a closed-loop connection to community resources as needs are identified in real-time can make a big difference too, one patient at a time.

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