Identifying and Investigating How Health-Related Social Needs are Addressed in Interventions that Prevent Avoidable Health Care Use

Primary care is an ideal venue to engage patients with high social needs, identify and address health-related social needs (HRSNs), and coordinate efforts to reduce avoidable health care use. As current and future primary care clinicians care for patients within a health care system that increasingly emphasizes value-based care for high-needs populations (1) it is critical to generate evidence that can help care teams understand how to deliver whole-person care to improve outcomes for high-risk populations.

Project Summary

The social determinants of health (SDH) are a critically important driver of population health (2), likely to a greater extent than medical care (3). In recent years, a growing understanding of the importance of SDH has driven a flurry of interest in addressing HRSNs in health care settings (4, 5). In this context, this study aims to 1) conduct a systematic review of interventions that reduced avoidable health care use while addressing HRSNs and 2) investigate the underlying theoretical frameworks and workflows that allowed these interventions to simultaneously address patients’ HRSNs and medical needs.

Addressing HRSNs

A 2017 review of interventions to address social and economic needs sheds light on the knowledge gaps we seek to address (6). First, the review found that many published studies contained low-quality evidence, and a dearth of studies focused on common healthcare utilization outcomes. Second, despite this review’s impressive breadth, it did not examine many interventions that may have addressed HRSNs. Due to the review’s primary focus on social and economic interventions, it did not include ‘blended’ interventions with a combination of social and medical intervention components. Additionally, we are unaware of any combined synthesis of the evidence on interventions to address HRSNs and interventions to reduce avoidable health care use in populations with high social risk.

The overall goal of this project will be to identify and investigate how HRSNs are addressed in interventions that prevent avoidable health care use. The proposed project can inform national best practices for addressing HRSNs in primary care settings.

Supporting Literature:

HHS NEWS: HHS To Deliver Value-Based Transformation in Primary Care. U.S. Centers for Medicare & Medicaid Services. https://www.cms.gov/newsroom/press-releases/hhs-news-hhs-deliver-value-based-transformation-primary-care. Updated April 22, 2019. Accessed May 8, 2019.
Wilkinson RG, Marmot M. Social determinants of health: the solid facts. World Health Organization; 2003.
Schroeder SA. Shattuck Lecture. We can do better–improving the health of the American people. N Engl J Med. 2007;357(12):1221-1228.
Accountable Health Communities Model. U.S. Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/ahcm/. Accessed May 8, 2019.
The Playbook: Resources for People with Behavioral Health and Social Needs. Institute for Healthcare Improvement. https://www.bettercareplaybook.org/population/people-behavioral-health-and-social-needs. Accessed May 8, 2019.
Gottlieb LM, Wing H, Adler NE. A Systematic Review of Interventions on Patients’ Social and Economic Needs. Am J Prev Med. 2017;53(5):719-729.