Addressing social determinants: Scaling up partnerships with community-based organization networks

As health care payment models become more value-based, health care systems are increasingly interested in approaches that address both medical needs and social determinants of health.

This isn’t surprising. Services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-medical risk factors have been shown to improve health outcomes and reduce the cost of care. This is particularly true for “high-need, high-cost” people who have complex health conditions and social risk factors and who often have significant functional limitations.