A Culture of Health: Creating a Model to Integrate Social Determinants of Health into Primary Care Settings

In this time of rising costs, there has been a renewed focus within the healthcare sector on social determinants of health (SDH). Issues such as food insecurity, homelessness, limited transportation, and exposure to violence can all strongly influence a person’s mental and physical well-being. Often, efforts to address these issues are disconnected from the primary health setting. This disconnect can be costly, not only to the individuals who are suffering, but also to the systems that are charged with their care.

The Culture of Health Project was created with a grand idea in mind, to create a model for healthcare systems that integrates services designed to address SDH. To do so involves a three-pronged approach; first, identify what social determinants are having the greatest impact in a community, second, identify services that could lower health costs by addressing those issues, and finally, identify payment streams (or lack thereof) that fund them. In order to create this model we engaged with a large integrated health delivery system encompassing several hospitals and over 100 patient care locations across four counties in Pennsylvania.

As a demonstration, maternal and child health statistics were reviewed for the four counties. While reviewing for youth exposure to violence, we found child abuse report rates above the state average in three of the counties; further, one of those counties was above average for infant mortality. We also examined maternal health behaviors and found below state average rates in two counties for early/adequate prenatal care and higher rates of percent of births to young unwed mothers.

Resource reviews were conducted in order to identify programs that could help. Nurse Family Partnership (NFP) was identified as an exemplary program that addresses SDH with a positive return on investment. NFP increases maternal access to prenatal care by eliminating transportation barriers. It has also been shown to reduce child abuse rates through increases in parenting education and improved social supports. While NFP already existed within each county, largely funded through the federal dollars, services were often underutilized.

Through conversations with healthcare and NFP service providers, efforts are underway to more seamlessly integrate these services to increase utilization; one effort involves having an NFP representative regularly present at local healthcare offices. This coordination of services allows for better patient outcomes while potentially lowering health costs for these higher risk patients. This small demonstration with NFP is helping to develop a model to illustrate how we may be able to use savings in medical claims costs to invest in social services in the future.