1932

Abstract

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

Loading

Article metrics loading...

/content/journals/10.1146/annurev-publhealth-061022-050026
2024-05-20
2024-05-23
Loading full text...

Full text loading...

/deliver/fulltext/publhealth/45/1/annurev-publhealth-061022-050026.html?itemId=/content/journals/10.1146/annurev-publhealth-061022-050026&mimeType=html&fmt=ahah

Literature Cited

  1. 1.
    Aceves B, De Marchis E, Loomba V, Brown EM, Gottlieb LM. 2023.. Stakeholder perspectives on social screening in US healthcare settings. . BMC Health Serv. Res. 23::246
    [Crossref] [Google Scholar]
  2. 2.
    Albertson EM, Chuang E, O'Masta B, Miake-Lye I, Haley LA, Pourat N. 2022.. Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. . Popul. Health Manag. 25::7385
    [Crossref] [Google Scholar]
  3. 3.
    Alderwick H, Hutchings A, Briggs A, Mays N. 2021.. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. . BMC Public Health 21::753
    [Crossref] [Google Scholar]
  4. 4.
    Allen M, Brown E, Gottlieb LM, Fichtenberg C. 2022.. Community-level actions on the social determinants of health: a typology for hospitals. . Health Aff. Forefront, Oct. 11. https://doi.org/10.1377/forefront.20221006.388060
    [Crossref] [Google Scholar]
  5. 5.
    Alley DE, Asomugha CN, Conway PH, Sanghavi DM. 2016.. Accountable health communities—addressing social needs through Medicare and Medicaid. . N. Engl. J. Med. 374::811
    [Crossref] [Google Scholar]
  6. 6.
    Am. Hosp. Assoc. 2017.. AHA annual survey database—2017. Am. Hosp. Assoc., Chicago:. https://www.ahadata.com/system/files/media/file/2020/04/2017%20AHA%20Survey%20File%20Layout.pdf
  7. 7.
    Amarasingham R, Xie B, Karam A, Nguyen N, Kapoor B. 2018.. Using community partnerships to integrate health and social services for high-need, high-cost patients. Issue Brief, Commonw. Fund, New York:. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2018_jan_amarasingham_integrating_health_social_services_high_need_high_cost_ib.pdf
  8. 8.
    Bakshi S, Carlson LC, Gulla J, Wang P, Helscel K, et al. 2022.. Improving care coordination and reducing ED utilization through patient navigation. . Am. J. Manag. Care 28::2016
    [Crossref] [Google Scholar]
  9. 9.
    Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. 2018.. The effects of integrated care: a systematic review of UK and international evidence. . BMC Health Serv. Res. 18::350
    [Crossref] [Google Scholar]
  10. 10.
    Beidler LB, Razon N, Lang H, Fraze TK. 2022.. “ More than just giving them a piece of paper”: interviews with primary care on social needs referrals to community-based organizations. . J. Gen. Intern. Med. 37::416067
    [Crossref] [Google Scholar]
  11. 11.
    Benach J, Vives A, Amable M, Vanroelen C, Tarafa G, Muntaner C. 2014.. Precarious employment: understanding an emerging social determinant of health. . Annu. Rev. Public Health 35::22953
    [Crossref] [Google Scholar]
  12. 12.
    Berkowitz SA. 2023.. Health care professionals take individual and organizational responsibility for addressing social needs. . NEJM Catal. 4:(4). https://doi.org/10.1056/CAT.23.0062
    [Google Scholar]
  13. 13.
    Berkowitz SA, Brown P, Brotman DJ, Deutschendorf A, Dunbar L, et al. 2016.. Case study: Johns Hopkins Community Health Partnership: a model for transformation. . Healthcare 4::26470
    [Crossref] [Google Scholar]
  14. 14.
    Berkowitz SA, Parashuram S, Rowan K, Andon L, Bass EB, et al. 2018.. Association of a care coordination model with health care costs and utilization: The Johns Hopkins Community Health Partnership (J-CHiP). . JAMA Netw. Open 1::e184273
    [Crossref] [Google Scholar]
  15. 15.
    Berkowitz SA, Terranova J, Hill C, Ajayi T, Linsky T, et al. 2018.. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. . Health Aff. 37::53542
    [Crossref] [Google Scholar]
  16. 16.
    Berry C, Paul M, Massar R, Marcello RK, Krauskopf M. 2020.. Social needs screening and referral program at a large US public hospital system. , 2017.. Am. J. Public Health 110::S21114
    [Crossref] [Google Scholar]
  17. 17.
    Berwick DM, Nolan TW, Whittington J. 2008.. The triple aim: care, health, and cost. . Health Aff. 27::75769
    [Google Scholar]
  18. 18.
    Bielaszka-DuVernay C. 2011.. Vermont's Blueprint for medical homes, community health teams, and better health at lower cost. . Health Aff. 30::38386
    [Crossref] [Google Scholar]
  19. 19.
    Bieler G, Paroz S, Faouzi M, Trueb L, Vaucher P, et al. 2012.. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. . Acad. Emerg. Med. 19::6368
    [Crossref] [Google Scholar]
  20. 20.
    Boyum S, Kreuter MW, McQueen A, Thompson T, Greer R. 2016.. Getting help from 2–1–1: a statewide study of referral outcomes. . J. Soc. Serv. Res. 42::40211
    [Crossref] [Google Scholar]
  21. 21.
    Braveman P, Egerter S, Williams DR. 2011.. The social determinants of health: coming of age. . Annu. Rev. Public Health 32::38198
    [Crossref] [Google Scholar]
  22. 22.
    Brewster AL, Wilson TL, Frehn J, Berish D, Kunkel SR. 2020.. Linking health and social services through area agencies on aging is associated with lower health care use and spending. . Health Aff. 39::58794
    [Crossref] [Google Scholar]
  23. 23.
    Brown DM, Hernandez EA, Levin S, De Vaan M, Kim M-O, et al. 2022.. Effect of social needs case management on hospital use among adult Medicaid beneficiaries: a randomized study. . Ann. Intern. Med. 175::110917
    [Crossref] [Google Scholar]
  24. 24.
    Bryson JM, Crosby BC, Stone MM. 2015.. Designing and implementing cross-sector collaborations: needed and challenging. . Public Adm. Rev. 75::64763
    [Crossref] [Google Scholar]
  25. 25.
    Butler E, Morgan A, Kangovi S. 2020.. Screening for unmet social needs: patient engagement or alienation?. NEJM Catal. https://doi.org/10.1056/CAT.19.1037
    [Google Scholar]
  26. 26.
    Byhoff E, Taylor LA. 2019.. Massachusetts community-based organization perspectives on Medicaid redesign. . Am. J. Prev. Med. 57::S7481
    [Crossref] [Google Scholar]
  27. 27.
    Carey G, Crammond B. 2015.. Action on the social determinants of health: views from inside the policy process. . Soc. Sci. Med. 128::13441
    [Crossref] [Google Scholar]
  28. 28.
    Carroll-Scott A, Henson RM, Kolker J, Purtle J. 2017.. The role of nonprofit hospitals in identifying and addressing health inequities in cities. . Health Aff. 36::11029
    [Crossref] [Google Scholar]
  29. 29.
    Cartier Y, Fichtenberg C, Burnett J, Ricks-Stephen C. 2023.. Barriers to social service organization uptake of community resource referral platforms. . Ann. Fam. Med. 21::4031
    [Google Scholar]
  30. 30.
    Castrucci BC, Auerbach J. 2019.. Meeting individual social needs falls short of addressing social determinants of health. . Health Aff. Forefront, Jan. 16. https://doi.org/10.1377/forefront.20190115.234942
    [Google Scholar]
  31. 31.
    Cené CW, Viswanathan M, Fichtenberg CM, Sathe NA, Kennedy SM, et al. 2023.. Racial health equity and social needs interventions: a review of a scoping review. . JAMA Netw. Open 6::e2250654
    [Crossref] [Google Scholar]
  32. 32.
    Chidambaram P, Burns A. 2022.. 10 things about long-term services and supports (LTSS). Issue Brief, KFF, San Francisco:. https://www.kff.org/medicaid/issue-brief/10-things-about-long-term-services-and-supports-ltss/
  33. 33.
    Chisolm DJ, Brook DL, Applegate MS, Kelleher KJ. 2019.. Social determinants of health priorities of state Medicaid programs. . BMC Health Serv. Res. 19::167
    [Crossref] [Google Scholar]
  34. 34.
    Chuang E, Brewster A, Knox M, Resnick A. 2020.. California's Medi-Cal health homes program: findings from early implementation efforts. Rep., Calif. Initiat. Health Equity Action
  35. 35.
    Chuang E, O'Masta B, Albertson EM, Haley LA, Lu C, Pourat N. 2019.. Whole person care improves care coordination for many Californians. Health Policy Brief, UCLA Cent. Health Policy Res., Los Angeles, CA:. https://healthpolicy.ucla.edu/publications/Documents/PDF/2019/wholepersoncare-policybrief-sep2019.pdf
  36. 36.
    Chuang E, Pourat N, Haley LA, O'Masta B, Albertson EM, Lu C. 2020.. Integrating health and human services in California's Whole Person Care Medicaid 1115 waiver demonstration. . Health Aff. 39::63948
    [Crossref] [Google Scholar]
  37. 37.
    Clemans-Cope L, Wishner JB, Allen EH, Lallemand N, Epstein M, Spillman BC. 2017.. Experiences of three states implementing the Medicaid health home model to address opioid use disorder—case studies in Maryland, Rhode Island, and Vermont. . J. Subst. Abuse Treat. 83::2735
    [Crossref] [Google Scholar]
  38. 38.
    Cole MB, Nguyen KH, Byhoff E, Murray GF. 2022.. Screening for social risk at federally qualified health centers: a national study. . Am. J. Prev. Med. 62::67078
    [Crossref] [Google Scholar]
  39. 39.
    Conrad DA, Vaughn M, Grembowski D, Marcus-Smith M. 2016.. Implementing value-based payment reform: a conceptual framework and case examples. . Med. Care Res. Rev. 73::43757
    [Crossref] [Google Scholar]
  40. 40.
    Conrad P. 1992.. Medicalization and social control. . Annu. Rev. Sociol. 18::20932
    [Crossref] [Google Scholar]
  41. 41.
    Conrad P, Mackie T, Mehrotra A. 2010.. Estimating the costs of medicalization. . Soc. Sci. Med. 70::194347
    [Crossref] [Google Scholar]
  42. 42.
    Corallo B, Moreno S. 2023.. Analysis of recent national trends in Medicaid and CHIP enrollment. Issue Brief, KFF, San Francisco:. https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/
  43. 43.
    Crocker H, Kelly L, Harlock J, Fitzpatrick R, Peters M. 2020.. Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives. . BMC Health Serv. Res. 20::515
    [Crossref] [Google Scholar]
  44. 44.
    Crook HL, Zhao AT, Saunders RS. 2021.. Analysis of Medicare Advantage plans’ supplemental benefits and variation by county. . JAMA Netw. Open 4::e2114359
    [Crossref] [Google Scholar]
  45. 45.
    CSDH (Comm. Soc. Determ. Health). 2008.. Closing the gap in a generation: health equity through action on the social determinants of health. Rep. WHO/IER/CSDH/08.1, World Health Organ., Geneva:. https://iris.who.int/bitstream/handle/10665/69832/WHO_IER_CSDH_08.1_eng.pdf
  46. 46.
    De Marchis EH, Torres JM, Benesch T, Fichtenberg C, Allen IE, et al. 2019.. Interventions addressing food insecurity in health care settings: a systematic review. . Ann. Fam. Med. 17::43647
    [Crossref] [Google Scholar]
  47. 47.
    Doty MM, Tikkanen R, Shah A, Schneider EC. 2020.. Primary care physicians’ role in coordinating medical and health-related social needs in eleven countries. . Health Aff. 39:(1):11523
    [Crossref] [Google Scholar]
  48. 48.
    Durfey SNM, Gadbois EA, Meyers DJ, Brazier JF, Wetle T, Thomas KS. 2021.. Health care and community-based organization partnerships to address social needs: Medicare Advantage plan representatives’ perspectives. . Med. Care Res. Rev. 79::24454
    [Crossref] [Google Scholar]
  49. 49.
    Eder M, Henninger M, Durbin S, Iacocca MO, Martin A, et al. 2021.. Screening and interventions for social risk factors: technical brief to support the US Preventive Services Task Force. . JAMA 326::141628
    [Crossref] [Google Scholar]
  50. 50.
    Fichtenberg C, Delva J, Minyard K, Gottlieb LM. 2020.. Health and human services integration: generating sustained health and equity improvements. . Health Aff. 39::56773
    [Crossref] [Google Scholar]
  51. 51.
    Fichtenberg C, Fraze TK. 2023.. Two questions before health care organizations plunge into addressing social risk factors. . NEJM Catal. 4:. https://doi.org/10.1056/CAT.22.0400
    [Google Scholar]
  52. 52.
    Fichtenberg CM, De Marchis EH, Gottlieb LM. 2022.. Understanding patients' interest in healthcare-based social assistance programs. . Am. J. Prev. Med. 63::S10915
    [Crossref] [Google Scholar]
  53. 53.
    Finkelstein A, Zhou A, Taubman S, Doyle J. 2020.. Health care hotspotting—a randomized, controlled trial. . N. Engl. J. Med. 382::15262
    [Crossref] [Google Scholar]
  54. 54.
    Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, Ciliska D, Kouyoumdjian F, Hwang SW. 2011.. Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. . BMC Public Health 11::638
    [Crossref] [Google Scholar]
  55. 55.
    Fraze T, Lewis VA, Rodriguez HP, Fisher ES. 2016.. Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients. . Health Aff. 35::210915
    [Crossref] [Google Scholar]
  56. 56.
    Fraze TK, Brewster AL, Lewis VA, Beidler LB, Murray GF, Colla CH. 2019.. Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals. . JAMA Netw. Open 2::e1911514
    [Crossref] [Google Scholar]
  57. 57.
    Freed M, Biniek JF, Damico A, Neuman T. 2022.. Medicare Advantage in 2022: enrollment update and key trends. Issue Brief, KFF, San Francisco:
  58. 58.
    Frehn JL, Brewster AL, Shortell SM, Rodriguez HP. 2022.. Comparing health care system and physician practice influences on social risk screening. . Health Care Manag. Rev. 47::E110
    [Crossref] [Google Scholar]
  59. 59.
    Gagnon K, Ortiz-Siberón A, Patel N, James R, Hawk M, et al. 2022.. Identifying facilitators, barriers, and strategies to implement social determinants of health screening, referral, and follow-up in the US: a scoping review protocol. . JBI Evid. Synth. 20::156877
    [Crossref] [Google Scholar]
  60. 60.
    Garg A, Boynton-Jarrett R, Dworkin PH. 2016.. Avoiding the unintended consequences of screening for social determinants of health. . JAMA 316::81314
    [Crossref] [Google Scholar]
  61. 61.
    Gifford K, Lashbrook A, Barth S, Nardone M, Hinton E, et al. 2021.. States respond to COVID-19 challenges but also take advantage of new opportunities to address long-standing issues: results from a 50-state Medicaid Budget Survey for SFY 2021 and 2022. Issue Brief, KFF, San Francisco:. https://files.kff.org/attachment/Report-States-Respond-to-COVID-19-Challenges.pdf
    [Google Scholar]
  62. 62.
    Gilmer TP, Avery M, Siantz E, Henwood BF, Center K, et al. 2018.. Evaluation of the behavioral health integration and complex care initiative in Medi-Cal. . Health Aff. 37::144249
    [Crossref] [Google Scholar]
  63. 63.
    Gold R, Kaufmann J, Cottrell EK, Bunce A, Sheppler CR, et al. 2023.. Implementation support for a social risk screening and referral process in community health centers. . NEJM Catal. 4:(4). https://doi.org/10.1056/CAT.23.0034
    [Google Scholar]
  64. 64.
    Gottlieb L, Ackerman S, Wing H, Manchanda R. 2017.. Understanding Medicaid managed care investments in members’ social determinants of health. . Popul. Health Manag. 20::3028
    [Crossref] [Google Scholar]
  65. 65.
    Gottlieb LM, DeSilvey SC, Fichtenberg C, Bernheim S, Peltz A. 2023.. Developing national social care standards. . Health Aff. Forefront, Feb. 22. https://doi.org/10.1377/forefront.20230221.857308
    [Google Scholar]
  66. 66.
    Gottlieb LM, Garcia K, Wing H, Manchanda R. 2016.. Clinical interventions addressing nonmedical health determinants in Medicaid managed care. . Am. J. Manag. Care 22::37076
    [Google Scholar]
  67. 67.
    Gottlieb LM, Wing H, Adler NE. 2017.. A systematic review of interventions on patients’ social and economic needs. . Am. J. Prev. Med. 53::71929
    [Crossref] [Google Scholar]
  68. 68.
    Gubits D, Shinn M, Wood M, Bell S, Dastrup S, et al. 2016.. Family Options Study: 3-year impacts of housing and services interventions for homeless families. Rep., U.S. Dep. Hous. Urban Dev., Washington, DC:. https://www.huduser.gov/portal/sites/default/files/pdf/Family-Options-Study-Full-Report.pdf
  69. 69.
    Gunja M, Gumas ED, Williams RD II. 2023.. U.S. health care from a global perspective, 2022: accelerating spending, worsening outcomes. Issue Brief, Commonw. Fund, Washington, DC:. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
    [Google Scholar]
  70. 70.
    Gurewich D, Garg A, Kressin NR. 2020.. Addressing social determinants of health within healthcare delivery systems: a framework to ground and inform health outcomes. . J. Gen. Intern. Med. 35::157175
    [Crossref] [Google Scholar]
  71. 71.
    Guth M. 2022.. Section 1115 waiver watch: approvals to address health-related social needs. Issue Brief, KFF, San Francisco:. https://www.kff.org/medicaid/issue-brief/section-1115-waiver-watch-approvals-to-address-health-related-social-needs/
  72. 72.
    Hinton E, Raphael J. 2023.. 10 things to know about Medicaid managed care. Issue Brief, KFF, San Francisco:. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/
  73. 73.
    Hinton E, Stolyar L. 2021.. Medicaid authorities and options to address social determinants of health (SDOH). Issue Brief, KFF, San Francisco:
  74. 74.
    Honsberger K, Tanga AM. 2020.. Social determinants of health referrals in Medicaid and the role of Medicaid managed care contracts. Fact Sheet, Natl. Acad. State Health Policy, Portland, ME:. https://downloads.aap.org/MedHome/pdf/SHD%20Fact%20Sheet%20Medicaid2.pdf
  75. 75.
    Horwitz LI, Chang C, Arcilla HN, Knickman JR. 2020.. Quantifying health systems’ investment in social determinants of health, by sector, 2017–19. . Health Aff. 39::19298
    [Crossref] [Google Scholar]
  76. 76.
    Howden-Chapman P, Bennett J, Edwards R, Jacobs D, Nathan K, Ormandy D. 2023.. Review of the impact of housing quality on inequalities in health and well-being. . Annu. Rev. Public Health 44::23354
    [Crossref] [Google Scholar]
  77. 77.
    Iott B, Anthony D. 2023.. Provision of social care services by US hospitals. . Milbank Q. 101::60135
    [Crossref] [Google Scholar]
  78. 78.
    Jin B, Xue L, Lovelace J, Doebler DA, Roberts ET. 2022.. Examination of differences in nonmedical supplemental benefit coverage for dual-eligible enrollees in Medicare Advantage in 2021. . JAMA Netw. Open 5::e2235161
    [Crossref] [Google Scholar]
  79. 79.
    Johnson D, Saavedra P, Sun E, Stageman A, Grovet D, et al. 2012.. Community health workers and Medicaid managed care in New Mexico. . J. Community Health 37::56371
    [Crossref] [Google Scholar]
  80. 80.
    Johnson KA, Barolin N, Ogbue C, Verlander K. 2022.. Lessons from five years of the CMS accountable health communities model. . Health Aff. Forefront, Aug. 8. https://www.doi.org/10.1377/forefront.20220805.764159
    [Crossref] [Google Scholar]
  81. 81.
    Kachoria A, Sefton L, Miller F, Leary A, Goff S, et al. 2023.. Facilitators and barriers to care coordination between Medicaid accountable care organizations and community partners: early lessons from Massachusetts. . Med. Care Res. Rev. 80::50718
    [Crossref] [Google Scholar]
  82. 82.
    Kaltenborn Z, Paul K, Kirsch JD, Aylward M, Rogers EA, et al. 2021.. Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. . BMC Health Serv. Res. 21::338
    [Crossref] [Google Scholar]
  83. 83.
    Katch H, Bailey P. 2020.. Medicaid doesn't pay for housing: Here's what it can do to help meet enrollees' social needs. . Health Aff. Forefront, Jan. 17. https://doi.org/10.1377/forefront.20200110.134351
    [Google Scholar]
  84. 84.
    Kaufman B, Spivack BS, Stearns SC, Song PH, O'Brien EC. 2019.. Impact of accountable care organizations on utilization, care, and outcomes: a systematic review. . Med. Care Res. Rev. 76::25590
    [Crossref] [Google Scholar]
  85. 85.
    Knowles M, Khan S, Palakshappa D, Cahill R, Kruger E, et al. 2018.. Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. . J. Health Care Poor Underserved 29::18191
    [Crossref] [Google Scholar]
  86. 86.
    Koh KA, Racine M, Gaeta JM, Goldie J, Martin DP, et al. 2020.. Health care spending and use among people experiencing unstable housing in the era of accountable care organizations. . Health Aff. 39::21423
    [Crossref] [Google Scholar]
  87. 87.
    Korenstein D, Duan K, Diaz MJ, Ahn R, Keyhani S. 2016.. Do health care delivery system reforms improve value? The jury is still out. . Med. Care 54::5566
    [Crossref] [Google Scholar]
  88. 88.
    Kornfield T, Kazan M, Frieder M, Duddy-Tenbrunsel R, Donthi S, Fix A. 2021.. Medicare Advantage plans offering expanded supplemental benefits: a look at availability and enrollment. Issue Brief, Commonw. Fund, Washington, DC:. https://www.commonwealthfund.org/publications/issue-briefs/2021/feb/medicare-advantage-plans-supplemental-benefits
  89. 89.
    Kreuter M, Garg R, Thompson T, McQueen A, Javed I, et al. 2020.. Assessing the capacity of local social services agencies to respond to referrals from health care providers. . Health Aff. 39::67988
    [Crossref] [Google Scholar]
  90. 90.
    Kreuter MW, Thompson T, McQueen A, Garg R. 2021.. Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. . Annu. Rev. Public Health 42::32944
    [Crossref] [Google Scholar]
  91. 91.
    Krist AH, Davidson KW, Ngo-Metzger Q, Mills J. 2019.. Social determinants as a preventive service: US Preventive Services Task Force methods considerations for research. . Am. J. Prev. Med. 57::S612
    [Crossref] [Google Scholar]
  92. 92.
    Kushner J, McConnell KJ. 2019.. Addressing social determinants of health through Medicaid: lessons from Oregon. . J. Health Politics Policy Law 44::91935
    [Crossref] [Google Scholar]
  93. 93.
    Landers G, Minyard K, Lanford D, Heishman H. 2020.. A theory of change for aligning health care, public health, and social services in the time of COVID-19. . Am. J. Public Health 110::S17880
    [Crossref] [Google Scholar]
  94. 94.
    Lantz PM. 2019.. The medicalization of population health: Who will stay upstream?. Milbank Q. 97::3639
    [Crossref] [Google Scholar]
  95. 95.
    Larimer ME, Malone DK, Garner MD, Atkins DC, Burlingham B, et al. 2009.. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. . JAMA 301::134957
    [Crossref] [Google Scholar]
  96. 96.
    Long CL, Franklin SM, Hagan AS, Li Y, Rastegar JS, et al. 2022.. Health-related social needs among older adults enrolled in Medicare Advantage. . Health Aff. 41::55762
    [Crossref] [Google Scholar]
  97. 97.
    Ludwig J, Duncan GJ, Gennetian LA, Katz LF, Kessler RC, et al. 2012.. Neighborhood effects on the long-term well-being of low-income adults. . Science 337::150510
    [Crossref] [Google Scholar]
  98. 98.
    MACPAC (Medicaid CHIP Paym. Access Comm.). 2018.. . Medicaid's role in housing. Issue Brief, MACPAC, Washington, DC:. https://www.macpac.gov/wp-content/uploads/2021/06/Medicaids-Role-in-Housing-1.pdf
  99. 99.
    Mann C, Reyneri DG. 2022.. New policy opens the door for states to address drivers of health in Medicaid. . Commonw. Fund Blog, April 19. https://www.commonwealthfund.org/blog/2022/new-policy-opens-door-states-address-drivers-health-medicaid
    [Google Scholar]
  100. 100.
    Mattessich P, Monsey B. 2001.. Wilder Collaboration Factors Inventory. St Paul, MN:: Wilder Res.
  101. 101.
    Mattessich PW, Rausch EJ. 2014.. Cross-sector collaboration to improve community health: a view of the current landscape. . Health Aff. 33::196874
    [Crossref] [Google Scholar]
  102. 102.
    Mays G, Mamaril C, Timsina L. 2016.. Preventable death rates fell where communities expanded population health activities through multisector networks. . Health Aff. 35::200513
    [Crossref] [Google Scholar]
  103. 103.
    McCarthy ML, Li Y, Elmi A, Wilder ME, Zheng Z, Zeger SL. 2022.. Social determinants of health influence future health care costs in the Medicaid cohort of the District of Columbia study. . Milbank Q. 100::76184
    [Crossref] [Google Scholar]
  104. 104.
    McConnell KJ, Renfro S, Lindrooth RC, Cohen DJ, Wallace NT, Chernew ME. 2017.. Oregon's Medicaid reform and transition to global budgets were associated with reductions in expenditures. . Health Aff. 36::45159
    [Crossref] [Google Scholar]
  105. 105.
    McConnell KJ, Rowland R, Nevola A. 2023.. A Medicaid benefit for health-related social needs. . JAMA Health Forum 4::e225407
    [Crossref] [Google Scholar]
  106. 106.
    Meyers DJ, Durfey SNM, Gadbois EA, Thomas KS. 2019.. Early adoption of new supplemental benefits by Medicare Advantage plans. . JAMA 321::223840
    [Crossref] [Google Scholar]
  107. 107.
    Meyers DJ, Tucher E, Thomas KS. 2022.. Addressing social needs through Medicare Advantage plans’ supplemental benefits—a potential not yet realized. . JAMA Netw. Open 5::e2235164
    [Crossref] [Google Scholar]
  108. 108.
    Murray GF, Rodriguez HP, Lewis VA. 2020.. Upstream with a small paddle: how ACOs are working against the current to meet patients’ social needs. . Health Aff. 39::199206
    [Crossref] [Google Scholar]
  109. 109.
    Naeem J, Miff S. 2023.. Reducing emergency department utilization and costs through addressing health-related social needs: outcomes from the Accountable Health Communities model in Dallas. . In Proceedings of AcademyHealth Annual Research Meeting, Seattle, WA:, June 24–27 . https://academyhealth.confex.com/academyhealth/2023arm/meetingapp.cgi/Paper/57564
  110. 110.
    Omerov P, Craftman AG, Mattsson E, Klarare A. 2020.. Homeless persons’ experiences of health and social care: a systematic, integrative review. . Health Soc. Care Community 28::111
    [Crossref] [Google Scholar]
  111. 111.
    Papanicolas I, Woskie LR, Orlander D, Orav EJ, Jha AK. 2019.. The relationship between health spending and social spending in high-income countries: How does the US compare?. Health Aff. 38::156775
    [Crossref] [Google Scholar]
  112. 112.
    Parish W, Beil H, D'Arcangelo N, Romaire M, Haber S, Rojas-Smith L. 2023.. Healthcare utilization and expenditure impacts for subpopulations facing multiple barriers to healthcare in the Accountable Health Communities model. . In Proceedings of AcademyHealth Annual Research Meeting, Seattle, WA:, June 24–27. https://academyhealth.confex.com/academyhealth/2023arm/meetingapp.cgi/Paper/58243
  113. 113.
    Park AM, Anderson AL, Nguyen JD, Saltzman DA, Kastetter BL, et al. 2015.. 182 assessing economic and health care access social determinants of health in the emergency department. . Ann. Emerg. Med. 66::S65
    [Crossref] [Google Scholar]
  114. 114.
    Pourat N, Chen X, O'Masta B, Haley LA, Zhou W, Haile M. 2023.. Final evaluation of California's Health Homes Program (HHP). Rep., UCLA Cent. Health Policy Res., Los Angeles:. https://healthpolicy.ucla.edu/sites/default/files/2023-07/final-evaluation-of-california-health-homes-program.pdf
  115. 115.
    Pourat N, Chuang E, O'Masta B, Haley LA, Chen X, et al. 2022.. Final evaluation of California's Whole Person Care (WPC) Program. Rep., UCLA Cent. Health Policy Res., Los Angeles:. https://healthpolicy.ucla.edu/publications/Documents/PDF/2023/Final-Evaluation-of-CA-Whole-Person-Care-Report.pdf
  116. 116.
    Probyn K, Engedahl MS, Rajendran D, Pincus T, Naeem K, et al. 2021.. The effects of supported employment interventions in populations of people with conditions other than severe mental health: a systematic review. . Prim. Health Care Res. Dev. 22::e79
    [Crossref] [Google Scholar]
  117. 117.
    Roberts SR, Crigler J, Ramirez C, Sisco D, Early GL. 2015.. Working with socially and medically complex patients: when care transitions are circular, overlapping, and continual rather than linear and finite. . J. Healthc. Qual. 37::24565
    [Crossref] [Google Scholar]
  118. 118.
    Rowen NP, Stewart L, Saunders RS. 2022.. Evaluation of supplemental benefits across Medicare Advantage plans and beneficiary demographic characteristics, 2019 to 2022. . JAMA Netw. Open 5::e2233020
    [Crossref] [Google Scholar]
  119. 119.
    Rozier MD. 2020.. Nonprofit hospital community benefit in the U.S.: a scoping review from 2010 to 2020. . Front. Public Health 8::72
    [Crossref] [Google Scholar]
  120. 120.
    Rutledge RI, Romaire MA, Hersey CL, Parish WJ, Kissam SM, Lloyd JT. 2019.. Medicaid accountable care organizations in four states: implementation and early impacts. . Milbank Q. 97::583619
    [Crossref] [Google Scholar]
  121. 121.
    Ryan JL, Franklin SM, Canterberry M, Long CL, Bowe A, et al. 2023.. Association of health-related social needs with quality and utilization outcomes in a Medicare Advantage population with diabetes. . JAMA Netw. Open 6::e239316
    [Crossref] [Google Scholar]
  122. 122.
    Sandberg SF, Erikson C, Owen R, Vickery KD, Shimotsu ST, et al. 2014.. Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. . Health Aff. 33::197584
    [Crossref] [Google Scholar]
  123. 123.
    Satherley R-M, Lingam R, Green J, Wolfe I. 2021.. Integrated health services for children: a qualitative study of family perspectives. . BMC Health Serv. Res. 21::167
    [Crossref] [Google Scholar]
  124. 124.
    Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II. 2021.. Mirror 2021: reflecting poorly. Fund Rep., Commonw. Fund, Washington, DC:. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
  125. 125.
    Shaheen A, Squire MA, Gay H, Rana SY, Gwynne M, Gupta SK. 2023.. System approaches to social determinants of health screening and intervention. . NEJM Catal. 4:(4). https://doi.org/10.1056/CAT.22.0361
    [Crossref] [Google Scholar]
  126. 126.
    Shavit S, Aminawung JA, Birnbaum N, Greenberg S, Berthold T, et al. 2017.. Transitions clinic network: challenges and lessons in primary care for people released from prison. . Health Aff. 36::100615
    [Crossref] [Google Scholar]
  127. 127.
    Shin P, Rosenbaum S, Somodevilla A, Handley M, Morris R, et al. 2021.. Review of social determinants of health terms in 2019–2020 state Medicaid managed care contracts. Rep., Milken Inst. Sch. Public Health, Georgetown Univ:. https://geigergibson.publichealth.gwu.edu/sites/g/files/zaxdzs4421/files/2023-08/rwjf-mmc-sdoh-contract-review-1213-1.pdf
  128. 128.
    Singer SJ, Kerrissey M, Friedberg M, Phillips RS. 2020.. A comprehensive theory of integration. . Med. Care Res. Rev. 77::196207
    [Crossref] [Google Scholar]
  129. 129.
    Sonik R, Brown C, Campa M, Sorto G, Perez Y, et al. 2023.. Tracing social needs after screening and referral in a primary care setting. . In Proceedings of the AcademyHealth Annual Research Meeting, Seattle, WA:, June 24–27. https://academyhealth.confex.com/academyhealth/2023arm/meetingapp.cgi/Paper/59924
  130. 130.
    Spillman BC, Allen EH, Lallemand N, Spencer A, Richardson E, et al. 2018.. Report to Congress on the Medicaid Health Home State Plan Option. Washington, DC:: Urban Inst.
  131. 131.
    Steeves-Reece AL, Nicolaidis C, Richardson DM, Frangie M, Gomez-Arboleda K, et al. 2023.. Fostering positive patient experiences during phone-based social needs interventions: a qualitative study from the Accountable Health Communities model in Oregon. . In Proceedings of the AcademyHealth Annual Research Meeting, Seattle, WA:, June 24–27. https://academyhealth.confex.com/academyhealth/2023arm/meetingapp.cgi/Paper/57526
  132. 132.
    Sterling S, Chi F, Weisner C, Grant R, Pruzansky A, et al. 2018.. Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs. . Prev. Med. Rep. 11::15459
    [Crossref] [Google Scholar]
  133. 133.
    Taira BR, Yadav K, Perez Y, Aleman A, Steinberg L, et al. 2023.. A formative evaluation of social care integration across a safety-net health system. . NEJM Catal. 4:(4). https://doi.org/10.1056/CAT.22.0232
    [Google Scholar]
  134. 134.
    Taylor LA, Byhoff E. 2021.. Money moves the mare: the response of community-based organizations to health care's embrace of social determinants. . Milbank Q. 99::171208
    [Crossref] [Google Scholar]
  135. 135.
    Taylor LA, Tan AX, Coyle CE, Ndumele C, Rogan E, et al. 2016.. Leveraging the social determinants of health: What works?. PLOS ONE 11::e0160217
    [Crossref] [Google Scholar]
  136. 136.
    Thomas KS, Durfey SNM, Gadbois EA, Meyers DJ, Brazier JF, et al. 2019.. Perspectives of Medicare Advantage plan representatives on addressing social determinants of health in response to the CHRONIC Care Act. . JAMA Netw. Open 2::e196923
    [Crossref] [Google Scholar]
  137. 137.
    Thompson FJ, Farnham J, Tiderington E, Gusmano MK, Cantor JC. 2021.. Medicaid waivers and tenancy supports for individuals experiencing homelessness: implementation challenges in four states. . Milbank Q. 99::64892
    [Crossref] [Google Scholar]
  138. 138.
    Tikkanen RS, Schneider EC. 2020.. Social spending to improve population health—does the United States spend as wisely as other countries?. N. Engl. J. Med. 382::88587
    [Crossref] [Google Scholar]
  139. 139.
    Towe VL, Leviton L, Chandra A, Sloan JC, Tait M, Orleans T. 2016.. Cross-sector collaborations and partnerships: essential ingredients to help shape health and well-being. . Health Aff. 35::196469
    [Crossref] [Google Scholar]
  140. 140.
    Vickery KD, Bodurtha P, Winkelman TNA, Hougham C, Owen R, et al. 2018.. Cross-sector service use among high health care utilizers in Minnesota after Medicaid expansion. . Health Aff. 37::6269
    [Crossref] [Google Scholar]
  141. 141.
    Vickery KD, Shippee ND, Menk J, Owen R, Vock DM, et al. 2020.. Integrated, accountable care for Medicaid expansion enrollees: a comparative evaluation of Hennepin Health. . Med. Care Res. Rev. 77::4659
    [Crossref] [Google Scholar]
  142. 142.
    Wang E, Gilbert A, Wessels A. 2019.. The Food Pharmacy Network: an alternative method for addressing food insecurity and an assessment of its effectiveness (OR02–08–19). . Curr. Dev. Nutr. 3::nzz051.OR0208–19
    [Google Scholar]
  143. 143.
    Wang M, Levi R, Seligman H. 2021.. New SNAP eligibility in California associated with improved food security and health. . Prev. Chronic Dis. 18::200587
    [Crossref] [Google Scholar]
  144. 144.
    Yue D, Pourat N, Essien EA, Chen X, Zhou W, O'Masta B. 2022.. Differential associations of homelessness with emergency department visits and hospitalizations by race, ethnicity, and gender. . Health Serv. Res. 57::24962
    [Crossref] [Google Scholar]
  145. 145.
    Zhu X, Weigel P, Baloh J, Nataliansyah M, Gunn N, Mueller K. 2019.. Mobilising cross-sector collaborations to improve population health in US rural communities: a qualitative study. . BMJ Open 9::e030983
    [Crossref] [Google Scholar]
/content/journals/10.1146/annurev-publhealth-061022-050026
Loading
/content/journals/10.1146/annurev-publhealth-061022-050026
Loading

Data & Media loading...

Supplemental Material

  • Article Type: Review Article
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error