Diffusion of community health workers within Medicaid managed care: A strategy to address social determinants of health

Social determinants of health (SDH), including where people live, their economic security, their educational attainment, their access to affordable and nutritious food, and their degree of social inclusion, have a greater impact on health than does the health care system. A recent study surveying patients attending primary care clinics revealed that nearly half experienced adverse social determinants but their providers were unaware because they didn’t ask questions about SDH. Yet, despite the importance and prevalence of adverse SDH in the patient population, our predominant fee-for-service incentive system strongly favors investments in individually focused “downstream” medical care at the expense of population-focused “upstream” prevention and social services, where adverse SDH could be addressed.

Addressing SDH in clinical settings under the current incentive system is a challenge. While primary care providers recognize that social needs are as important as medical needs, they feel ill-equipped to address them. And resources available to them, even in Patient-Centered Medical Homes, are generally insufficient to address the enormity of adverse social determinants once uncovered. Is there a viable health service approach in which “downstream” resources are re-allocated “upstream” to address social needs?