Completing the Circle of Care

Collaborations to Close the Loop on Social Determinants on Health


A true systems-level commitment to addressing the social factors related to individual and community health outcomes requires two critical components. First, organizations involved in the continuum of care should adjust their corporate vocabulary to address the nuances of the social factors. Second, collaborations between healthcare organizations and community-based organizations need to become seamless in order to address any potential care gaps.

The U.S. Department of Health and Human Services defines Social Determinants of Health (SDOH) as, “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks“. SDOH are often grouped into 5 categories: economic stability, education access, healthcare access, neighborhood/environment, and social and community support.

Though the SDOH are typically the default categorization used to identify social factors, it is important for agencies to understand the differences between SDOH, social risk factors and social needs. Social Determinants of Health refer to broad systemic realities and can be either positive or negative, depending on the population and impact (e.g. economic stability, education). Social risk factors are the specific issues which have a direct negative impact on the individual and communities (e.g. housing insecurity, high unemployment).  And, a social need is typically the key priority from the perspective of the individual being served. For instance, someone can be unemployed but their priority need may be to find housing.

Understanding the differences in these categorizations will allow organizations to better design interventions to meet the actual needs of the community in a meaningful way.

Which leads to the second key component – seamless collaborations between health systems and community-based organizations to effectively address social factors.

Though there have been many great examples of health systems working closely with community-based partners in order to “go upstream” and address the key social factors which affect health outcomes and increase overall healthcare costs, many of these collaborations are not fully integrated.  There are referral processes, Health Information Exhcanges (HIE) and perhaps even co-location, which are great starting points. But there is rarely a shared strategy, shared social risk factors/social needs assessments, or shared population-level data analytics.  Each organization still ultimately operates in a silo, which increases the potential for care gaps and quite possibly creates unintended barriers to accomplishing the primary goals.

To truly “close the loop” and create a comprehensive care continuum that positively impacts social factors, health systems and community-based organizations would be best served to meaningfully align processes. Though this may be more time-intensive in terms of initial planning and defining operational rules of engagement, it may be a more efficient use of time than implementing a process which has little to no real long-term impact.

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