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Authored by Alyssa Crawford, Senior Health Researcher, Mathematica 

There is a growing need to scale and sustain effective health-related social needs (HRSNs) screening, referral, community service navigation, and other supports. Most health care professionals agree that screening for and helping patients to address their HRSNs is an important part of health care. Many payers and accreditation bodies now require hospitals and other health care delivery organizations to do so.

These shifts reflect a greater understanding of the undeniable impacts of the social determinants of health (SDOH) on health and well-being. Some advocates and thought leaders are calling for a balance between identifying and addressing individuals’ HRSNs and improving SDOH at a population level. Connecting people to needed services is important but effecting positive changes for whole communities requires moving upstream to prevent HRSNs from occurring, promoting wellness, and paving a more effective path to achieving health equity.  

Cross-sector partnerships can play a pivotal role in accelerating efforts to address an individual’s HRSNs and in aligning those efforts with broader systems changes capable of improving SDOH in communities at large. As one example, Lake Chelan Health, a public critical access hospital in Chelan County, Washington, leans into building partnerships with other organizations in its region for these reasons. Its experience highlights lessons learned that can help other communities interested in addressing SDOH to improve HRSNs. Effective strategies to build partnerships for both purposes include:

• Establishing relationships and building trust with patients being screened for HRSNs and with organizations in other sectors that partner to address those needs
• Expanding the collective capacity of cross-sector partnerships to address individuals’ HRSNs by documenting what each member organization can offer and formalizing data sharing and referral pathways that help partnering organizations collaborate
• Partnering with public health agencies to address emerging needs, such as filling gaps in available services or developing campaigns to improve prevention, diagnosis, and treatment of particular chronic conditions
• Partnering with backbone organizations that serve as hubs for community-wide efforts to improve SDOH and catalyze collective action on upstream solutions
• Advancing new or revised policies with the potential to improve HRSNs or SDOH and to support the organizations partnering to achieve those goals

Many initiatives at the federal, state, and local level are encouraging and improving the capacity and effectiveness of cross-sector partnerships to benefit individuals and communities. For example:

• Healthy People 2030 includes a new goal to leverage multisector partnerships, including those that involve health departments, to address SDOH and improve health equity. A National Association of City and County Health Officials (NACCHO) toolkit offers guidance on operational steps towards this goal.
• The U.S. Department of Health and Human Services’ Call to Action for addressing health-related social needs and Strategic Approach to address SDOH name opportunities for collaborating across sectors, including data sharing between health and human services providers, filling gaps in the services and infrastructure needed to address HRSNs, and blending financing.
• Expansions in the authorities of state Medicaid agencies and Medicare Advantage plans mean they can offer services that meet patients’ HRSNs and reduce inequities and encourage formalized partnerships to aid and supplement these expansions of HRSNs screening, referral, and services. For instance, state Medicaid agencies using section 1115 waivers are required to partner with other state and local entities to cover services and supports that address HRSNs.
• The U.S. Administration for Community Living has established a Center of Excellence for community care hubs, which can play a meaningful role in aligning the efforts of partners across multiple sectors to connect individuals to the care they need.

There are also many resources that can help to establish and guide the work of multisector community partnerships. For example, NACCHO’s Mobilizing for Action through Planning and Partnership is a community-driven strategic planning process for developing community health needs assessments and community health improvement plans. It’s part of NACCHO’s Public Health Infrastructure and Systems program, which has a wealth of other resources design to foster collaboration between public health and other sectors, including faith-based organizations, health care organizations, health centers, and community leaders. The Association for State and Territorial Health Officials (ASTHO) also has many resources on SDOH, including a recent podcast on working across sectors to maximize investments. The Getting Further Faster Community of Practice website contains resources specific to preventing chronic disease, including recordings of webinars on scaling and sustaining SDOH initiatives and using community-informed data to advance health equity.

Multisector community partnerships should leverage these opportunities and resources to collaboratively improve SDOH to address and prevent HRSNs.

Acknowledgment: We thank Ray Eickmeyer, Director of Emergency Medical Services and Paratransit at Lake Chelan Health, for sharing information about the partnerships and social needs screening efforts in Chelan County Washington for this blog post.