Addressing social determinants of health: Case studies from Epic's Population Health Steering Board

More than two thirds of health care organizations report that they now assess populations for SDOH as part of ongoing care management. The 2 most frequent interventions cited are referral to community service agencies (78.1%) and help with navigation of services (76.6%). Notwithstanding this self-reported activity, many health care organizations are still early in their journey to build an effective overall system for SDOH screening, intervention, and measurement.

The Robert Wood Johnson Foundation 2016 report, Using Social Determinants of Health Data to Improve Health Care and Health: A Learning Report, cited some of the challenges faced by health care organizations. These include: (1) Lack of multi-sector collaboration within and across social services and health care sectors, (2) Lack of flexible technologies and interoperable information technology (IT) systems, and (3) Lack of standards, tools, best practices, and research evidence.

The case studies that follow speak to these challenges and were contributed by organizations participating in the Epic Population Health Steering Board over the past year, representing both US and Scandinavian health care delivery systems.