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Better Collaboration Required to Address Social Determinants


The last few decades have seen some amazing advances in medical science. However, as organizations like the Centers for Disease Control and Prevention (CDC) point out, genes, biology and health behaviors together only account for about 25 percent of population health predilection. The remaining factors are conditions and environment in which people are born, grow, live, work, and age ... typically referred to as social determinants of health (SDOH).

A person's health is affected by these many factors that extend beyond healthcare alone. For instance, inequitable access to care means that at-risk populations can - and usually do - end up sicker with higher medical costs in the end because of how long it typically takes them to find a source of care.

Thanks in large part to better data, there is a much greater understanding of how socioeconomic status, education levels and environmental conditions affect population health. By considering these underlying societal factors and improving access to basic social services available in local communities, there are now some creative efforts underway by government, private sector and nonprofit organizations to "level the playing field" for access to care and services.

Initiatives like the federal government's Healthy People 2020 - along with efforts in many states and local communities - are making progress to address and reduce inequities. Over the last 30 years, the organization has encouraged collaboration, empowered individuals to make informed health decisions and contributed better data by measuring the impact of prevention activities. The CDC and nonprofits such as The Health Research & Educational Trust (an affiliate of the American Hospital Association) are laying the groundwork by creating guidelines for cultivating community partnerships that can address and improve SDOH.

Even as pressure grows for providers to bear greater financial risk for outcomes and many hospitals in the U.S. screen patients for social needs, these screenings are still inconsistent. A recent Deloitte study revealed nearly three-quarters of surveyed hospitals simply don't have the adequate resources to address patients' social needs. And even the best care may not lower readmission rates in communities with deep SDOH inequities, underscoring that additional spending alone on healthcare services is not in and of itself a pathway to better health outcomes.

Providers and health plans are realizing more and more the critical role information technology plays in addressing overall community health and how data from EMRs, HEDIS and other sources can illuminate social determinants of health for specific populations and communities, giving providers better opportunities to support patient care teams by connecting their patients and members with local services.

Many providers and health plans are partnering with third-party organizations to start communicating across the board and ultimately match patient needs to appropriate community services. Centauri Health Solutions helps to address SDOH with a fully integrated, proprietary platform that provides quick access to a database of more than 200,000 local services and programs. By uncovering social service needs and tracking the referral workflow, case managers can better achieve the intersection point between patients and the services they need.

As the American healthcare system approaches 20 percent of the gross domestic product, one thing is clear: meaningful improvement to the effects of SDOH will require sustained collaboration among government agencies, healthcare providers, health plans, and the many organizations filling the needs within communities. Rapidly evolving technology solutions will remain a key element to bring everything together, helping to make healthcare more efficient and accessible to all.

Nashville-based Julie Goldberg, PhD, is a product development specialist who applies behavioral research to health technology for Centauri Health Solutions, Inc. She is the author of more than 50 peer-reviewed articles and professional presentations on the psychology of medical decision-making and health outcomes. Goldberg earned her doctorate in social psychology from the University of California, Berkley and her undergraduate degree in sociology and master's degree in counseling psychology from the University of Pennsylvania. For more information, go online to


Centauri Health Solutions


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Centauri Health Solutions, Health Inequities, Health Outcomes, Julie Goldberg, Social Determinants of Health, Social Services
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