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A growing number of initiatives are expanding to address social determinants of health. Payers, health systems, community-based organizations, and government entities are partnering together to create statewide efforts to improve community health and social care. COVID-19 continues to expose deep vulnerabilities in the U.S.

Digital health platforms can play an important role, providing a common system to connect multiple different types of stakeholders from hospitals to primary care providers, social services to food banks, mental health providers to payers. Technology platforms like Unite Us, Now-Pow, and Citiblock can coordinate social and medical care teams, and provide 24/7 access points. Remote monitoring and mobile devices are widely adopted tools to help identify non-medical needs and connect people with necessary services and then track outcomes.


States are seeking to expand the scope of social determinants of health interventions to include more patient populations and social issues. Rather than focus on enrollees with complex health conditions, programs are now considering the social and economic factors of all members.

  • Unite Louisiana uses the Unite Us technology platform to connect clinicians and social service providers to serve the health and social needs within communities and parishes statewide. The Unite Louisiana network is supported by Aetna Better Health of Louisiana and Louisiana Healthcare Connections. They are connecting Medicaid and Dual-eligible Special Needs Plan (DSNP) members with social services.
  • Utah and several health systems have come together to drive better health outcomes by streamlining access to critical social services and then removing barriers in areas such as housing, education, transportation, and jobs with technology.


Collaboration between health care organizations and social service networks in the community have been associated with higher performance and reduced health costs, and some partnerships have substantially improved workforce shortages.

  • VAAACares, a statewide one-stop coalition providing care coordination, care transitions, and other services, reduced the 30-day readmission rate from 18.2 to 8.9 percent through their partnership with four health systems, 69 skilled nursing facilities, and 3 health plans.
  • Elder Services of the Merrimack Valley, an Area Agency on Aging (AAA) in northeast Massachusetts, and their network of community partners have shown an 11 percent reduction in the total cost of care through their collaboration with health care organizations.
  • The Veterans Health Administration, through the Veteran Directed Care program, has had purchasing agreements over the last decade with CBO network organizations across 37 states to provide nursing-home-eligible veterans with a counselor and a monthly budget to obtain the long-term services and supports they need to live in the community – at about one-third of the cost of a nursing home.


Medicaid-specific initiatives are focusing on addressing social needs. These include models under the Center for Medicare and Medicaid Innovation (CMMI), Medicaid delivery system and payment reform initiatives, and options under Medicaid. Managed care plans and providers also are engaged in activities to identify and address social needs. For example, 19 states required Medicaid managed care plans to screen for and/or provide referrals for social needs in 2017.

Health plans that administer Medicare and Medicaid plans can see the advantages and the upside of investing in social determinants of health especially in the shift to value-based care and risk-sharing models that prioritize care quality and outcomes.

What’s in the Future?

Scaling partnerships across the country and statewide with shared investments and shared technology infrastructure from both health care and social services.

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