At NCQA, we believe that delivering high-quality care requires collaboration across diverse areas of health care. We also recognize the importance of addressing social determinants of health (SDOH) as part of improving care delivery, health outcomes and health equity. Toward that end, with sponsorship from Janssen Scientific Affairs, NCQA created the Social Determinants of Health Resource Guide to help health plans and clinically integrated networks (CIN) develop strategies and initiatives to address SDOH.
The SDOH Resource Guide centers around SDOH strategy and is organized into six sections: Assessment Design, SDOH Data, Data Sharing, Integration and Quality, Collaboration with Community-Based Organizations, Measurement and Evaluation and Quality Improvement. It features 21 in-the-field examples highlighting real-world interventions that health plans and CINs are implementing to address social needs for their commercial populations. The guide also contains information on how NCQA programs address SDOH.
The World Health Organization defines SDOH as “the conditions in which people live, work, and play - they are the forces and institutions shaping the conditions of daily life, including political systems, public policies and social norms.” This involves factors such as socioeconomic status, education, employment, environment, social supports and income—just to name a few. SDOH can be protective and improve health or they can be adverse and undermine it.
Health care systems were once considered the main driver of health outcomes, but now we know that SDOH play an even greater role. Recent attention to improving health equity has focused on mitigating the negative impact on health from unfair distribution of SDOH such as unsafe housing, employment instability and food insecurity.
The Healthy People 2030 initiative includes an example of how poverty affects health outcomes. In 2018, 11.8% of persons were living below the poverty threshold. Those living in poverty are less likely to have stable housing, and access to healthy food and healthcare, and are also more likely to die from preventable diseases.
Using the SDOH Resource Guide
Although the literature contains many examples of addressing SDOH for Medicaid and Medicare populations, less has been published about commercially insured populations. The SDOH Resource Guide highlights activities that health plans and CINs have implemented to address SDOH, and can inform other organizations about potential strategies to help them address SDOH in their own populations.
Strategies and interventions in the guide focus on commercial populations, but the lessons it contains can apply across populations to improve health outcomes and health equity.
Incorporating Data and Measurement into SDOH Strategies
The Data Sharing, Integration and Quality section of the Resource Guide explores how data sharing and integration can help organizations develop a comprehensive understanding of an individual’s medical and social needs. Health Information Exchanges and Community Information Exchanges are highlighted as strategies used by health plans and CINs to share information, improve data interoperability, and collaborate with organizations to better care.
Measurement and Evaluation addresses approaches to measure SDOH program outcomes and assess program impact. Measure stratification and risk adjustment are two techniques emphasized in the Resource Guide, which supports equitable measurement and enhances performance reporting.
Share Your Thoughts in the Community Forum:
- From your perspective, why is SDOH important to address?
- What is your organization doing to address SDOH? What are some lessons learned you can share with other organizations?
- How has your organization used data and measurement in implementing SDOH strategies?