Where to start when it comes to social determinants of health: A practical approach

Care management & redesign SDOH & health equity

As part of a Zoom panel for the Physician-Focused Payment Model Technical Advisory Committee (PTAC), I shared some of the lessons we’ve learned at the Camden Coalition with other healthcare leaders looking to address social determinants of health (SDOH) and the inequities experienced in so many communities across the country. The common theme throughout my remarks was this: Addressing social determinants of health does not require the activation of a health policy brain trust or even large sums of money. More often than not, all it takes to improve the health and well-being of many individuals negatively affected by SDOH is common sense, good communication, and flexibility.

The Camden Coalition has been on the ground addressing social determinants of health in the city of Camden — and, in recent years, throughout South Jersey — for nearly two decades. Along the way, we’ve learned valuable lessons about what works and what doesn’t through trial and error. Below are some of the lessons we’ve gleaned from our experience.

You have to engage with communities to help communities. Too often, solutions are imposed on communities from the outside, whether by researchers, government officials, or nonprofits. By partnering with community groups, you can learn what they need and let them be part of the solution.

When COVID-19 first hit Camden, NJ, our nearby hospitals and local government rushed to set up a massive COVID testing center on the site of a former prison. All of our contacts in the community, including our Community Advisory Committee, community engagement team, and staff members who live in Camden, told us it was a terrible site. Aside from the inherent trauma of its location, the site wasn’t connected to public transportation or near a high-traffic pedestrian area, making it difficult to access without a car.

But the plan went forward, and we did end up doing a lot of COVID tests — for people who drove in from the suburbs.

As a coalition, we have built trusting and collaborative partnerships, and are able to engage in honest conversations both when things go right and when they don’t. After honest follow-up conversations with our hospital and government partners, we were able to come to an agreement that future COVID testing and vaccination sites would be located at sites near trains and buses, or in high-walking areas. The takeaway here is this: Listen to the people you are trying to help. Only by asking the community what they need can you direct your resources appropriately.

Whatever the amount of money, keeping funds flexible can increase effectiveness. At the Camden Coalition, we’ve found that flexibility of dollars is often more valuable than the amount you have to spend.

With support from local and national funders, we recently put out an request for proposals (RFP) to hospital and community-based maternal health organizations for a pilot program that would help connect pregnant individuals who sought help at emergency rooms or other social services organizations to prenatal care. As part of this program, pilot sites would gain access to data in our health information exchange (HIE) to identify pregnant individuals who had no evidence of prenatal care so they could be connected to resources. (Launched in 2010, the Camden Coalition HIE collects secure medical information from a variety of sources, including regional hospitals, primary care providers, laboratory and radiology groups, correctional facilities, and other licensed healthcare facilities and providers, to ensure continuum of care.) In addition, the Camden Coalition provided participating organizations with ongoing consultation to help them redesign workflows and protocols to ensure these individuals did not fall through the cracks.

Perhaps most significantly, we provided participating sites with a patient cost budget of $10,000 to use toward any expense that facilitated initiation and retention in prenatal care. Such expenses included transportation to and from doctor appointments, childcare vouchers, diaper programs, or the purchasing of baby items.

Much to our surprise, we were deluged by requests from healthcare providers in systems both large and small who wanted to work with us. Those ob-gyns were so grateful to have some extra funds they could use flexibly, to help a pregnant patient who needed childcare or transportation money to get to a first trimester checkup. It’s not possible to pay for such things out of a hospital budget, and the idea that providers could use $500 to help one pregnant woman on one particular day was so appreciated.

Interdependency is key. From examples listed above, a common theme arises: the need not only for collaboration and partnership, but interdependence and interconnectivity. For years, healthcare leaders have lamented the silos that plague our current system, the consequences of which were made all the more apparent during the COVID-19 pandemic. Collaborations and partnerships are a good start to addressing the barriers these silos build up, but we must go further and establish interdependence and interconnectivity between all involved. Only when the burden to succeed is shared across organizations, with each player having a stake and a seat at the table, can there be sustained progress in addressing social determinants.

For years now, the Camden Coalition has been championing the concept of ecosystems of care. We define these ecosystems as interconnected groups of organizations that are shaping and have been shaped in the environment in which they exist. Our ecosystem in Camden and, more broadly, South Jersey, includes consumers and families, health systems and practitioners, public health thinkers and doers, social service organizations, educators, first responders like police and fire, and more. Each of us is vital to this network.

Interdependence — from small community-based nonprofits to large hospital networks — is not only the core of ecosystems but also their strength and the key to their success. While ecosystems necessarily include backbone organizations like anchor hospitals, they flourish when informal networks come to the table, such as faith communities, recovery and support groups, and families. Through the creation of such ecosystems, addressing social determinants can occur on a community level — enabling local organizations to remain hyper-focused on what they do best, while working toward a shared goal to improve the health and well-being of those in need.