On Social Determinants Of Heath [SDOH]

Eight Data Sources from the CDC

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1. Chronic Disease Indicators – https://www.cdc.gov/cdi/index.html
2. Community Health Status Indicators (CHSI 2015) –http://wwwn.cdc.gov/CommunityHealth/
3. Health Indicators Warehouse – http://www.healthindicators.gov/
4. Interactive Atlas of Heart Disease and Stroke – http://nccd.cdc.gov/dhdspatlas/
5. National Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention Atlas – https://www.cdc.gov/nchhstp/atlas/index.htm
6. National Environmental Public Health Tracking Network – http://ephtracking.cdc.gov/showHome.action
7. The Social Vulnerability Index – http://svi.cdc.gov/
8. Vulnerable Populations Footprint Tool – http://www.communitycommons.org/chna/

MORE: https://www.goinvo.com/vision/determinants-of-health/


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6 Responses

  1. SDOH

    Managing population health costs over the long term and elevating health outcomes requires payers and providers alike to widen the lens to view the whole person. The medical model, even when viewed across the continuum – prevention, acute care, post-acute care and chronic care management – often ignores factors that can make or break health care interventions.

    Suppose we’re given this information about two seemingly identical patients, John and James, both members of the same Medicare Advantage plan: 82 year old male admitted to acute hospital after fall at home resulting in hip fracture, transferred to skilled nursing facility for rehab, now ready to be discharged back to home. Now, add this information: John is a federal government retiree living with his wife in a continuing care retirement community where there is an on-site dining facility and a medical practice that offers outpatient physical therapy. James, who left school after seventh grade and never earned a pension, lives alone in a regular apartment building where the elevators often break down.

    Absent recognition of social factors – family supports, literacy, nutrition and access to health care – we might expect John and James to receive the same plan of care and have the same outcomes. But when taking these factors into account, the health plan and the providers involved will see plainly that James needs a more holistic plan of care if he can hope to avoid downstream exacerbations that lead to recurrent acute care episodes and poorer health outcomes.

    Now, multiply John and James by tens of thousands. To be successfully accountable for population health in the right way, health plans and providers must identify the social factors of each person for whom they are responsible and be prepared to act on that knowledge. Sometimes this will translate to enhancing services offered within the available revenue; at minimum it ought to entail connecting enrollees/patients to appropriate community resources.

    Bob Atlas via Ann Miller RN MHA
    EBG Advisors



    SDOH are defined as “the conditions in which people are born, grow, live, work and age.”

    The multidimensional nature of SDOH reach far beyond poverty, requiring a systemic approach to effectively moderate their effects on health outcomes.
    The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.

    Dr. David E. Marcinko MBA


  3. 53% of Consumers Have at Least One Unmet Social Need

    McKinsey and Company recently released results from a survey on social determinants of health (SDoH). Here are some key findings from the report:

    • Half (53%) of consumers have at least one unmet social need (food, housing, safety, etc).
    • Food insecurity is the most commonly reported SDoH, experienced by 35% of consumers.
    • Consumers with unmet transportation needs are 2.6x more likely to report ER visits.
    • 45% of people with poor health reported multiple unmet social needs.
    • Consumers with food insecurity are 2.4x more likely to report multiple ER visits.

    Source: McKinseyand Company, April 2019


  4. How Much Does Your Education Level Affect Your Health?

    Some clever studies have teased out causal effects by taking advantage of natural experiments.



  5. 1 in 3 Physician Practices Do Not Screen Patients For Social Needs

    JAMA recently investigated screening prevalence for food, housing, transportation, utilities, and interpersonal violence needs among hospitals and practices. Here are some key findings:

    • 15.6% of physician practices report screening patients for all 5 social needs.
    • 1 in 4 hospitals report screening patients for all 5 social needs.
    • 8% of hospitals report not screening patients for social needs.
    • 1 in 3 physician practices report not screening patients for social needs.
    • Screening for violence was most common (practices: 56.4%; hospitals: 75%).

    Source: JAMA, September 18, 2019


  6. SDoH

    Payers, providers and other healthcare institutional stakeholders are essential components of SDoH solutions. And they are particularly effective when linked with community ‘influencer’ organizations that can provide local insights and serve as public healthcare rallying point.

    Families across the nation, urban and rural, are in crisis. They are wrestling with an array of financial burdens to a degree few ever experienced – unemployment, financial market downturn, business closures, and strained household budgets. People are being stressed-tested to the max. In the short-term, uncertainty about the COVID19 shutdown timeline and access to a safe, science validated vaccine is driving consumer anxiety. Add to the mix healthcare costs, already outpacing wages, with high deductible health plans and climbing out-of- pocket expenses, consumers are facing extraordinary financial health burdens. They are delaying care, skipping prescriptions, and ignoring chronic conditions.

    Social determinants of health SDOH are the circumstances in which people are born, grow up, live & work, their behaviors, and systems put in place to deal with healthcare. We know that socioeconomic disparities in income, literacy, housing, jobs, nutrition and education are forces that can have twice the impact on an individual’s health than biology, DNA, and clinical care.

    Health inequities are avoidable or unfair differences in distribution of health resources between diverse population groups. For example, life expectancy of a black Chicagoan is nearly 10-years lower than their white counterparts. Babies born 6 subway stops apart in New York City have a 9-year difference in life expectancy. COVID19 has highlighted these health inequities in terms of who gets tested, hospitalized and treated. It has been glaring in communities of color.

    There’s nothing like a pandemic to shine a bright light on gaps and imbalances in our healthcare system. And unfortunately, given the confluence of economic, political and healthcare forces we’re likely to see things get worse before they get better: increasing number of uninsured Americans, strained state Medicaid budgets, an aging chronic population, partisan gridlock stalling progress, and rampant mental health issues associated with the pandemic and its ‘life disruptors’. So indeed, it is going to take every healthcare stakeholders to ante-up and help solve disparities and inequities in our neighborhoods. Investing in epidemiological, data driven methodologies that support integrated community based SDoH programs focused on under-served populations will improve quality of life and over time, life expectancy.

    Lindsay Resnick – EVP
    Wunderman Thompson Health


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