Health systems, hospitals, and community health clinics have a substantial part to play in patients’ lives. As trusted sources of healthcare and information, US providers may help patients understand the links between unmet basic needs—or social determinants of health (SDOH)—and health while supporting patients in meeting these needs (see sidebar, “Unmet basic needs and other common SDOH terminology”). While unmet basic needs disproportionately affect Medicaid-insured patients, more than 45 percent of consumers across coverage types experience at least one unmet basic need. Even patients with higher salaries may be struggling with unmet needs. Ninety percent of the United States’ $3.8 trillion in annual healthcare expenditures are for people with chronic and mental-health conditions, with 60 percent of adults across the United States facing one chronic disease and 40 percent facing two or more chronic diseases.1 Unmet basic needs contribute to this by leading to clinical exacerbations, unnecessary and avoidable utilization, and poor outcomes. Individuals with unmet basic needs often have less access to healthcare and lower satisfaction with the care they do receive, compared with individuals whose basic needs have been met; they are also more than 2.5 times more likely to report poor physical health, more than five times more likely to report mental-health issues, and more than twice as likely to report higher healthcare utilization.2 Even employed individuals with one or more unmet basic needs were about 2.4 times more likely not to receive needed physical healthcare and to miss six or more days of work in the past 12 months.
While unmet basic needs disproportionately affect Medicaid-insured patients, more than 45 percent of consumers across coverage types experience at least one unmet basic need.
Addressing gaps in unmet needs may directly improve care for patients and communities while also contributing to economic productivity. In the COVID-19 era, providers are more closely examining how they can identify and address patients’ basic needs. There are actions for providers to consider, including collecting patient data, that may help identify the most effective interventions related to unmet basic needs.
How providers may create an action plan
Though provider systems are beginning to address unmet basic needs through efforts such as screening and closed-loop referrals, dedicated resource coordinators, and community partnerships, scaling from small initiatives that serve a subset of patients to hospital-wide programming is challenging. Barriers include limited resources, lack of data regarding which patients could benefit most from interventions, lack of system-wide coordination to identify needs and implement scaled solutions (for example, across sites, clinical departments, and programs), and uncertain economic return on investment.
No provider can ameliorate all social problems, nor should providers feel pressure to do so. However, provider systems—particularly those that are focused on value-based care—could prioritize efforts that would have the greatest impact on patient outcomes, align with current or desired capabilities and partnerships, and prove to be financially feasible.
The following are considerations for providers to build such programs. We present these steps sequentially, but they may be pursued in any order, or in parallel, depending on a provider’s current capabilities.
Linking unmet basic needs to strategic priorities
Consumers with higher levels of healthcare utilization are more likely to report unmet needs. Providers may want to begin the journey of addressing unmet basic needs for patients by considering the following actions:
- Determining how addressing patients’ unmet basic needs could advance the system’s strategic objectives. Patients’ unmet basic needs have a major influence on individual health outcomes, experience, and engagement. They are also closely tied to institutional strategic priorities such as patient experience, quality improvement, total cost of care, and value-based care. Providers could start by identifying which unmet basic needs most closely link to existing strategic priorities and capabilities and focusing on those (for example, by communicating the link with other leaders across the organization to gain traction and dedicate funding).
- Establishing an initial road map that prioritizes efforts. Unmet basic needs can link to several strategic priorities, and addressing SDOH can take various forms. Providers could prioritize where to start based on evidence of the impact of unmet basic needs on clinical outcomes, the prevalence of needs in communities, existing capabilities, or the feasibility of partnerships with community-based organizations or other healthcare organizations.
- Starting within your own walls. While there is ample opportunity to address unmet basic needs externally, healthcare providers could begin by driving impact within their own organizations. Applying a holistic lens to patient experience may uncover areas of unintended friction. For example, parking costs, shuttle services to and from the hospital, on-site food services, adequacy and timeliness of interpreter services, and availability of childcare when needed can all have an impact on the experiences of patients and their families. The Jackson Chance Foundation offers complimentary parking passes to families with children in the neonatal intensive care units at three Chicago hospitals, easing financial burdens and facilitating access to healthcare.3 Brigham and Women’s Hospital in Boston offers backup childcare while a parent attends an appointment.4 In addition to incorporating questions about unmet basic needs and their possible health effects into patient experience surveys, providers could survey frontline staff and patient advisers regarding potential improvements. Finally, providers could conduct exercises for patient journey-mapping to examine nonmedical barriers to care within the provider system.
Organizing for success
A comprehensive approach requires a strong and intentional organizational structure, yet stakeholders could start with bite-size pieces. As we discussed in “Emerging stronger from the crisis: What’s next for regional providers,” some “smaller initiatives, which may engage 20 percent or more of the workforce, create greater ownership and enable more employees to personally drive the transformation program.” Providers may consider the following steps:
- Identifying an executive SDOH lead. This person would be accountable for developing a cross-system strategy and setting up a cross-team structure, enabling the organization to comprehensively identify and address unmet basic needs through one system. Population health and community health staff make up important components of this structure. Additionally, clinical department leaders, nursing staff, and leaders in patient experience, quality and safety, and data and analytics could be part of a coordinated team effort of providing feedback and implementing solutions.
- Aligning incentives around unmet basic needs. This ensures a unified approach. Consider defining a reporting structure that promotes cross-team communication and coordination, and identify performance metrics that are tied to the success of these efforts. For example, the completion of a social risk assessment could be a process metric for primary-care physicians in value-based-care contracts.
- Understanding patient voices on an ongoing basis. Strong relationships with patients and community members could help inform programming. Provider systems may want to establish family and patient advisory councils and committees and make certain that these committees engage with leaders throughout the hospital system. Providers could also consider including community voices in their leadership structure, with appointed positions on the board or other leadership committees. For instance, hospitals such as Children’s Mercy in Kansas City, Children’s Hospital of Philadelphia, and Jefferson University Hospitals in Philadelphia have family advisory boards that collaborate with hospital leaders to share feedback, provide input on program development, and advocate for patients.5
Collecting data to identify necessary SDOH interventions
Data are essential in helping health systems better anticipate needs and help vulnerable patients receive support at both the individual and population levels. The ideal data collection and screening efforts are systematic yet thoughtful and should be conducted in destigmatizing, culturally sensitive ways. Providers could consider the following initiatives:
- Defining data collection priorities to support specific interventions. Providers could ensure that data collection efforts support better understanding of unmet basic needs and which existing programs meet those needs. For example, a provider that offers a nonemergency medical transportation program could know who has the need, where they live, and what additional needs the program could meet (for example, grocery or prescription pickup). Assessment of program feedback, engagement, and correlation with health outcomes measures—such as better control of a chronic health condition, stress reduction, reduced depression, or anxiety—ideally would be routine and could inform subsequent iterations of the program.
- Developing screening practices that reach a range of patients at meaningful moments. It is becoming more common for annual preventive visits to include screenings for unmet basic needs. However, this type of screening could happen in other high-value moments, such as before hospital discharge or during an emergency room visit. Additionally, some patients may prefer to self-screen and find resources to avoid perceived stigma; others may want to seek resources as needs arise instead of waiting for a provider visit. Providers could help patients by offering tech vendor platforms that offer self-screening and resource databases and may also partner with or direct patients to community resources such as United Way’s 211 helplines. For example, RWJBarnabas Health is launching a universal SDOH screening designed for patients to answer questions on their phones or in conversation with a provider; Boston Children’s Hospital partnered with Mass 211 (created by United Way), Boston Public Health Commission, United Way, and the Greater Boston Food Bank to launch a universal SDOH online-screening tool and resource connector across the state of Massachusetts; and multiple health systems have deployed platforms such as Aunt Bertha and Unite Us to provide community resource databases directly to patients.6
- Embedding screening into workflows to collect real-time data on patient needs. With frontline providers facing an increasing number of required tasks and screenings during medical visits, basic-needs screening and billing procedures (with Z-codes, for example) need to be quick and easy. Provider systems could achieve this by embedding these screening tools into the flow of the patient visit. For example, relevant screening questions could be within electronic health record (EHR) visit templates, or other care team members could conduct the screening (for example, when a medical assistant is taking vital signs). Boston Medical Center’s THRIVE screening program takes one minute to complete and is directly embedded into the EHR, enabling automated coding and resource referrals; RWJBarnabas Health’s universal SDOH screening will also be embedded into the EHR.7
- Supplementing individual data with community-level data. Public demographic data from sources such as the US Census Bureau and the USDA Household Food Security Survey could help provider systems understand rates of unmet basic needs in the communities they serve. Similarly, a growing market of data vendors calculate individual SDOH risk scores based on a combination of claims data and demographic data. Qualitative inputs from a variety of stakeholders—for example, patients and families, hospital employees, community members, and community leaders, including political, other healthcare system, and business leaders—could help make it personal. These groups may offer insights from advocates based on lived experience and help providers understand how to work with and within the broader community.
Partnerships may lessen the burden on providers to collect data about the broader community. For example, providers could collaborate with other local providers to complete community health-needs assessments (CHNAs), which are done every three years under the Affordable Care Act, instead of conducting these in an asynchronous and duplicative manner. Regional CHNA collaborations have taken place in several cities, counties, and states, including King County, Washington; Los Angeles County, California; Sioux Falls, South Dakota; and Maine and Utah.8
Developing a referral and support infrastructure
Once unmet basic needs are identified, providers could take the following actions to connect patients with community resources and help them access any benefits for which they may be eligible:
- Curating community resources, services, and referral platforms. Providers may benefit from strong relationships with community-based organizations. They could attempt “warm handoffs” between medical and social service providers to support the patient experience. Investing in referral infrastructure and technology for social services may help to automate this process. Through referral networks with closed-loop communication between healthcare providers and social service providers, healthcare providers could determine whether patients received services, thereby establishing a basis for further care coordination. And providers don’t have to curate and manage this process themselves—health systems such as Kaiser Permanente and Intermountain Healthcare have launched partnerships with referral platforms and community partners to improve care coordination and address economic and social factors that influence patients’ health.9
- Developing dedicated support to address unmet basic needs and referrals. Some hospitals are building teams of resource coordinators and training other staff, including patient navigators and community health workers, to identify unmet basic needs and refer patients to resources. This referral system reduces the burden on social workers. These supports may also generate financial returns for health systems; Penn Medicine’s IMPaCT program, which deploys community health workers to support high-risk patients, has achieved a 2:1 annual ROI in randomized controlled studies.10 Additionally, as payers increasingly expand supplemental benefits, such as medically tailored meals for patients with specific health conditions, providers may want to help patients understand which benefits are offered in their health plan and make referrals.
Once unmet basic needs are identified, providers could take actions to connect patients with community resources and help them access any benefits for which they may be eligible.
Measuring outcomes and sharing successes
Provider systems will likely need to define both what they hope to achieve and how they will measure their results. Sharing successful initiatives in the following ways may help other providers address unmet basic needs for their patients as well:
- Defining measures and working toward improvement. Providers could define measures based on potential impact. Ideally, these goals would be linked with overarching strategic KPIs. For instance, through efforts to standardize unmet-basic-needs screening and referrals, providers could track the percentage of patients screened and demonstrate whether unmet basic needs decrease among those who received referrals. Providers could tie these metrics to an overarching KPI regarding other screenings. After establishing measures and reasonable targets, providers could take a quality improvement or agile approach to improvement through iterative measurements and modifications informed by feedback from patients, families, community members, and staff.
- Understanding link to value. Providers could measure improvements across health outcomes and key indicators (for example, stress or behavioral-health metrics), in addition to being rigorous in tracking value. This exercise may help ensure that activities are matched to value for both the patient and the provider system. It could help providers assess when to shift to a different approach for more impact and may bolster the case to continue dedicating funding and resources toward high-impact efforts.
- Scaling and sharing successful initiatives. Provider systems could seek to scale successful initiatives and disseminate their findings. Sharing evidence-based solutions beyond a single-provider system has the potential to enhance care practices and improve health and well-being for many. For example, the Social Interventions Research & Evaluation Network (SIREN) at the University of California, San Francisco, offers curated resource libraries and evidence guides from leading health systems and other healthcare stakeholders to support best practices.11
Organizing and leading external SDOH activities
Improving population health requires going beyond addressing the unmet basic needs of individuals. Providers could collaborate with other stakeholders to offer SDOH services internally—for example, food pantries, mobile markets, and medical–legal partnerships—or externally, such as grocery store subsidy programs or housing collaboratives. Aspirational provider systems may envision moving further upstream to address unmet basic needs and root causes as part of a long-term strategic plan to improve health and well-being in their communities.
- Establishing ecosystems of care. The COVID-19 pandemic has accelerated care-delivery models, such as mobile care and in-home care for vulnerable populations, and ecosystems of care that address whole-person health are becoming increasingly common. In partnership with community entities such as schools and community organizations, providers could continue to test and expand innovative care-delivery models. Additional partnerships with organizations, such as payers, private businesses, and government agencies, could spark further ideas addressing unmet basic needs (for example, sharing information about community resources with employees or members or screening for unmet basic needs alongside blood pressure testing at community fairs). Finally, providers could help to fill gaps in local ecosystems where needed. For instance, if data collection efforts or feedback from community partners reveals a need for local affordable housing, health systems could work to address that need by convening local-housing-market stakeholders, supporting shelters and housing organizations, and directly investing in housing initiatives.
- Becoming an anchor organization in the community. As part of standard business practices, providers may want to consider the implications of their institutional decisions on community members’ health and access to resources. By providing benefits such as family leave, childcare, or local transportation assistance (such as bus passes), organizations demonstrate that they want their employees to be part of the broader community: for example, LifeBridge Health and Baltimore County’s “Live Near Your Work” program offers stipends for employees to buy homes near LifeBridge Health hospitals.12 On a larger scale, more than 60 healthcare systems have joined the Healthcare Anchor Network, signaling their commitment to building better local economies through programs such as intentionally increasing spending with local vendors and investing in affordable housing and economic development.13 Broadly, provider systems could work to ensure that their organizational practices as employers align with their clinical mission to improve health and well-being.
- Considering the provider system’s role as an employer in the community. Providers have an opportunity to address the unmet basic needs not only of their patients but also of their employees. Health systems often serve as major employers in their communities and could serve as role models by supporting whole-person health for their employees. Offerings such as childcare support, cafeteria discounts for employees facing food insecurity, or career training and advancement opportunities could have a significant positive impact on employees, their families, and the broader community. Further, these employees are likely patients themselves.
Provider systems at the forefront of addressing unmet basic needs will be part of a transformative era of delivering whole-person healthcare. This important work has value for patients and families, communities, and provider systems, and it is key to the industry’s movement into a new era of care.