Social Determinants of Health: Can ZIP Codes Define Health Outcomes?

Children eating a snack

When exploring your personal health narrative, it’s important to take note of the many external influences on your health and wellness – like your town’s air quality, or access to nutritious food. These elements play a major role in forming your personal health narrative, from start to finish.

A recently published Healthbox report, Root Causes of Health, explores findings on life expectancy which bring to light the idea that your ZIP code can carry more weight on your potential health outcomes than your genetic code.

For example, in the city of Chicago, individuals residing in “the loop” (the heart of downtown Chicago) have an average life expectancy of 83 years. For residents living in the nearby neighborhood of Washington Park – just three train stops south of downtown Chicago – the average lifespan is only 69 years. This gap in life expectancy, the report notes, is even larger than the life expectancy gap between the U.S. and Honduras.

In order to leverage insights like these to ignite actionable change across the health ecosystem, a lot more work needs to be done, notes Neil Patel, executive vice president at HIMSS and president of Healthbox, a HIMSS Innovation Company.

RELATED: Health Challenges in Underserved Communities

How is the U.S. Addressing Social Risks in Healthcare?

In the U.S. today, insights based on the social determinants of health are not always incorporated into a clinician’s diagnostic process. As a result, individuals from low-income or underserved communities can face worse health outcomes.

Consider this potential scenario: a patient who recently lost his job and became homeless arrives in the emergency department, presenting symptoms of influenza. Could the fact that he slept on the street last night play a role in his condition today?

“In the current system, the patient would just receive a diagnosis of exposure from a clinical standpoint,” said Patel. “This wouldn’t take into account if this person has housing security, how that may have influenced his health, and what measures can be taken to prevent similar instances in the future.”

These crucial insights are rarely considered when a patient enters the ED; physicians don’t have the capacity or the resources to help the patient outside of what they can diagnose in the clinical setting. Often, if this information is collected, instead of integrating this information into the care delivery process, it is shared with social workers. And while licensed social workers are employed by many U.S. hospitals and clinics, they are far and few. A 2017 report from the U.S. Bureau of Labor reveals that even in the state with the highest employment level for healthcare social workers (California), only one is employed per every 1,000 jobs. So what does this mean and how do we address it?

"The answer isn’t necessarily going to be, ‘Let’s just spend more money overall -- on social workers or social determinants.’ I think the underlying theory here is that if we invest more in social determinants, we’ll be able to spend less on traditional care delivery, or clinical medicine.”

As the U.S. transitions to value-based care, payment models need to be adjusted for the effects of social risk factors on health outcomes – or patients with more social risk factors will have worse outcomes regardless of quality, Healthbox’s report notes. A potential repercussion moving into value-based care is that providers could be incentivized to only see patients of a certain socioeconomic status in order to prevent their bottom line from being unfairly impacted due to poor patient outcomes when they are seemingly out of their control or ability to affect.

This HIMSSTV interview explores the idea of ‘wellcare’ and how it can be used to target social determinants of health before they have a negative impact on patients.

“The traditional care delivery system – as it’s constructed right now in the U.S. – is not really set up to have all of the impacts that are needed to change the trajectory of someone’s health, improve quality, decrease costs and help the patient return to a more healthy state. What’s changed the most is that now we’re starting to have more data to be able to make targeted interventions,” Patel said. “With this we’re able to track whether or not those interventions are successful and whether they’re actually having an impact as expected on cost, quality, and patient or physician experiences.”

Social Determinants of Health on a Global Scale

So how are other countries addressing the social determinants of health?

“When you look at countries where there is more socialized medicine, and more spending on social side of healthcare – non-clinical, or social versus clinical; it’s almost flipped,” said Patel. “Countries like the Netherlands spend far more on social determinants than they do on traditional care delivery in the U.S., where it’s kind of the opposite. A lot of other countries spending more on social determinants actually have lower total costs on healthcare spending, higher quality care, and healthier populations.”

As U.S. health systems are facing more economic risk, Patel is hopeful that the future of U.S. healthcare will invest more in social interventions. “Health systems in the U.S. are recognizing that they need to add more tools to their tool belt to have the impact that they’re now, or will be, fiscally responsible for.”

“There’s a lot of community resources out there that are available for these populations to help, so systems and payers don’t necessarily have to develop them themselves, unless they feel the market their patients are in is underserved,” said Patel. “There’s a lot of grant funding and public health funding that’s for community organizations to provide interventions that patients need. But often times, that information is very difficult for clinicians and their workflows to access so they can connect their patients with the resources they need.”

Activating Change Through Innovation

In a world with endless innovations evolving to improve care, the digital health sector shows major promise in combatting the threat of social risks affecting the root causes of health. A Patchwise Labs report predicts that the adoption of social technology will triple over the next five years and spur a wave of commercialization over the next three years.

Listen now or download for later: This episode of Innovation That Sticks investigates the ‘communication breakdown’ in healthcare, and explores how artificial intelligence and other innovative technologies can help move the needle and increase focus on the social determinants of health.

“When developing innovative solutions to address the social determinants of health, you first need to ask questions. For example, what community organizations exist that can benefit from this solution? How will it be easily accessible for physicians, nurses, social workers? What kind of experience will it provide on both sides? And how do I ensure there’s a feedback loop so I can tell if the patient is accessing these resources?”

To help health systems find answers to these questions, Healthbox convenes their internal stakeholders and helps get conversations started on topics like data infrastructure, so that their solutions can be implemented effectively. “We’re developing a framework that can help health systems that aren’t yet accustomed to thinking about their populations in this way, or feel they don’t have the resources they need for it. That is the reality for many U.S. health systems right now, which is why we’re trying to empower those organizations with information,” Patel said. “So we start the conversation and get them thinking about how social determinants can play a critical role in their patient’s health outcomes – so that they fully understand how they can make an impact there.”

Getting started could be as simple as building prompts into the electronic medical record, which would capture data on social determinants in addition to the other more obvious physical symptoms presenting, Patel said. “Then you can then take an approach with analytics, mine the data collected, look at it from a population level perspective, and then plan how you want to target and track interventions to improve outcomes. Over time, you can start to get some trending data and build strategies based on what you learn from that data.”

By incorporating the power of predictive analytics into care delivery – if implemented effectively – a healthcare crisis can be prevented long before it occurs by identifying metrics that correlate with social risks. The power of these insights can be leveraged to address major health disparities and inequities occurring across populations, or ZIP codes.

Driving change with insights on the social determinants of health relies heavily upon collaboration – especially between communities, healthcare stakeholders and innovators. “It’s knitting the systems that exist together and getting them to talk to each other,” Patel said.

Through innovation and collaboration, we will see just how much of an impact can be made by incorporating insights on the social determinants of health into care delivery. With the right sectors joining forces, meaningful change can occur and cascade throughout the health ecosystem and beyond.


Healthbox, a HIMSS Innovation Company, is a healthcare advisory firm that leading organizations trust with innovation and digital strategy development and execution. Healthbox drives innovation from the inside and out, helping organizations build internal innovation programs in addition to assessing the commercial potential of employee-led projects. They also help organization’s look to the market to find solutions to implement or invest in. Healthbox is proud to work with industry leaders who share their passion for building, harnessing, and advancing solutions to empower the reinvention of healthcare.

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Updated May 13, 2019