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Addressing Social Determinants of Health Through Multisector Collaborations and Community Engagement


Even before COVID-19, we knew that where a person lived impacted their health and well-being. But the pandemic has laid bare profound health disparities caused by structural inequity in communities across the U.S. To remove these inequities and eliminate health disparities, communities must engage people with lived experience to create systems that address the social determinants of health (SDOH).

Social determinants of health are 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. Safe housing, racism, job opportunities and environmental pollution are just a few examples of SDOH.

It is estimated that medical care accounts for just 20% of the modifiable factors that contribute to healthy outcomes for a population. The rest are social determinants of health, including health-related behaviors, socioeconomic factors and physical environment. We must treat community health improvement as a multisector challenge, or disparities in outcomes, quality of life and total cost of care will continue to increase.

Community Hub Models

Community-based organizations (CBOs) play an important role in improving population health by addressing SDOH. These organizations provide resources and supports that enable people to lead healthier lives and better connect to health care services. To successfully address inequities, CBOs must have the tools, resources and knowledge to navigate complex referral and payment relationships with the health care system and health plans. Community-based care coordination models that enable CBOs to scale, connect and sustain their services are essential.

Community hubs represent a model that can:

  • Empower CBOs by creating the capacity for them to establish partnerships and receive referrals from multiple health systems
  • Make it easier for health plans to pay for innovative services delivered by nonclinical CBOs and community health workers
  • Support workforce development for community health workers and other traditional health workers like birth doulas, personal health navigators and peer support specialists by providing ongoing evidence-based training and creating a mechanism for sustainable workforce growth

The Pathways Community HUB Institute (PCHI) Model is an example of an evidence-based community care coordination model that uses community health workers (CHWs) to build a care coordination network. CHWs engage community members at risk for poor health and social outcomes and assist with identifying and mitigating risk factors. The PCHI Model’s 21 pathways guide CHWs in helping people connect to resources that address needs such as housing, food security and access to a medical home.

The PCHI Model:

  • Requires Community HUBs to be certified, which helps ensure service delivery is consistent with the evidence base
  • Provides a framework for ensuring service delivery is documented and monitored for effectiveness
  • Uses outcomes-based payment that provides the accountability Medicaid and other funders require for services outside of the health care system.
  • Enables communities to better understand where there are gaps in services. This informs policy-making and improves resource allocation by aligning funding with demonstrated need for specific services that address SDOH.

Emerging Community Information Exchanges

Health information technology is evolving rapidly to meet the needs created by complex referral networks between health care and community-based services and supports. A key feature of community information exchanges (CIEs) is their ability to “close the loop” on referrals — meaning the CIE notifies the referring organization when a referred client has connected with the receiving organization. Technology companies are growing their networks rapidly as federal agencies, states and health plans grapple with how best to invest in and scale infrastructure. Pairing safe, privacy-focused technologies with CHW-led models to reach those most in need shows great potential for scaling access and alleviating SDOH.

Building Communitywide Solutions

More investments in community-led collaborative models are needed to streamline efforts to mitigate SDOH. The Gravity Project and Civitas Networks for Health are examples of organizations taking a lead in creating frameworks and forums for better alignment and collaboration. Continued investment in community-led models that ensure community-based organizations and community members with lived experience participate in designing solutions is vital to addressing the greatest threats to the health of our communities.

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