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Program Results Report

An RWJF Collection

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Using Social Determinants of Health Data to Improve Health Care and Health: A Learning Report

Someone points a finger at a location on a map.

Factors such as where we live, how much money we have, and our education level have been clearly linked to our health, well-being, and how long we live.

Yet until recently, collecting data about, and addressing the social determinants of health (SDOH) has largely been done outside health care systems.

A Robert Wood Johnson Foundation (RWJF) learning report sheds new light on current and potential future uses of SDOH-related data to improve health and health care and promote a Culture of Health.

Providers, social service agencies, insurers, and public health agencies have to attend to the strengths and needs of the people they serve, taking into account their economic, racial, ethnic, gender, and cultural characteristics. Additionally, changes in the health care landscape—including value-based reimbursement, increased health system and provider accountability, and the addition of millions of people to the health insurance rolls—have created incentives and demand for addressing SDOH in the health care system by connecting people to the services they need.

As these developments have been unfolding, RWJF consultants interviewed 38 leaders within and beyond the health sector who are working to address SDOH.

Many interviewees expressed optimism that addressing the social, housing, food, and other needs of patients, or connecting them to services that can do so, will allow health care systems to better allocate resources to improve outcomes and decrease utilization of health care services. Many also expressed interest and optimism in the potential for more passive forms of data collection—such as information provided by patients through medical devices and apps on smart phones—to increase understanding of population-level SDOH.

Changes in the health care landscape have created interest in collecting and using SDOH data and generated momentum and many good ideas. Noted the medical director with the Grand Rapids, Mich.-based Spectrum Health Center for Integrative Medicine:  

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The SDs are going to be as much a part of regular health care as treating blood pressure.

Robert Corey Waller

At the same time, interviewees also pointed to four types of challenges to the collection and use of SDOH data to improve health.

  • Lack of Knowledge and Consensus. In the absence of standards or tools, and without knowledge about best practices, health systems, social services agencies, and community coalitions create home-grown initiatives. There is no systematic mechanism for sharing best practices, struggles, successes, or failures.
  • Resource and Power Differences Between Social Services and Health Care Organizations. While health care and social services systems share goals, they have different perspectives. Health systems need better understanding of their communities, and social service organizations need to be open to change.
  • Lack of Effective Multi-Sector Collaboration. These collaborations need to address not only who will collect data and how, but how it will be made available to health care providers; how they will act on collected data; and how they will link patients back to social service or other providers.
  • Rigid Technology Systems. The right technologies need to be identified and developed. Electronic health records may not be the right tool; cloud-based technology may work better. Either way, sharing data across sectors is a major challenge.

Opportunities for Investment

There is wide recognition that the collection and use of SDOH data by the health care sectors is an emerging field. The field needs leadership and guidance—standards, tools, best practices, evidence, and more—on how best to improve individual and community health by addressing SDOH.

Throught the interviews and research, the consultants identified common perspectives, giving more weight to those from people who are already deeply involved in this work and those most backed up by evidence. Some key recommendations included:

  • Make SDOH Work Easier by Using a Population-Focused Approach: Develop and disseminate easy-to-use tools to assess the health of the local population.
  • Give the Field a Home Base: Consider a simple clearinghouse, a larger community with webinars, meetings, and opportunities for people to interact online, or something in between.
  • Provide Guidance: Develop and disseminate guidelines, best practices, and training for collecting, using, and sharing SDOH data.
  • Show How to Do this Work: Support demonstration and evaluation projects to provide models for collecting SDOH data and generating evidence about what works under what circumstances.
  • Facilitate Multi-Sector Collaborations to Promote Collection and Use of SDOH Data: Support studies of multi-sector collaborations that work with SDOH data, and develop guidance for collaborations on the collection and use of SDOH data to improve health outcomes.

Providing SDOH data to health care system providers, and bolstering the social service agencies that can address the social determinants of health, are key parts of building a Culture of Health.

Changes in the health care landscape are helping to generate even greater interest in collecting and using of SDOH data to help improve the health of individuals and communities. Despite the challenges, people are generally positive about moving toward widespread collection and use of SDOH data, and they are prepared to tackle some thorny issues. Now is the time is right for the health care system to get engaged in this work.

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