Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

Impact of hospital and health system initiatives to address Social Determinants of Health (SDOH) in the United States: a scoping review of the peer-reviewed literature

BACKGROUND

Hospital and health system initiatives addressing Social Determinants of Health (SDOH) are essential for achieving whole-person care and advancing health equity. Building on prior research characterizing these efforts (Part 1), this scoping review (Part 2) evaluates the effectiveness of these initiatives, with a focus on SDOH data integration, EHR utilization, and the broader scope of hospital efforts in addressing individual- and system-level determinants of health. Using an integrated conceptual framework combining the DeVoe & Cottrell framework for operational assessment and the National Academy of Medicine (NAM) 5A framework for systemic evaluation, this study provides a multidimensional assessment of hospital-based SDOH interventions.

METHODS

Guided by PRISMA-ScR criteria, this review analyzed 41 U.S.-based studies published between 2018 and 2023, identified through three academic databases. Eligible studies examined hospital initiatives addressing SDOH with measurable outcomes. Analyses assessed SDOH data collection, integration into care practices, EHR use, and overall initiative effectiveness.

RESULTS

Most studies (66%) were randomized controlled trials in urban settings (68%), targeting patients with chronic or mental health conditions (39%) or high-risk healthcare users (20%). Nearly half of initiatives (49%) addressed multiple SDOH domains, focusing on Social & Community Context, Economic Stability, and Neighborhood & Built Environment. Only 24% of initiatives utilized EHRs for SDOH data collection. EHR-based initiatives demonstrated significantly higher adherence to evidence-based practices, including use of community resource guides for referrals (90% vs. 45%, p = 0.013). Across all outcome measures, 79% demonstrated improvement, with no instances of worsening outcomes. However, 85% of initiatives lacked community-level SDOH data integration, and few employed upstream, universal strategies. Process, clinical, and social outcomes were unevenly prioritized, with only 10% of studies addressing all three outcome types.

CONCLUSIONS

While these initiatives reflect progress in integrating SDOH into care workflows and improving whole-person care at the individual level, progress toward health equity remains insufficient. Persistent gaps in EHR use, community-level data integration, and upstream strategies hinder systemic impact, potentially perpetuating disparities. Strengthening SDOH-EHR integration, fostering community partnerships, and supporting policy advocacy are critical to bridging individual and community needs. Future research should emphasize long-term, sustainable, and community-level impacts of hospital-led SDOH interventions.

Social Risks and Health Care Use in Medically Complex Patients

Importance

Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions.

Objective

To evaluate the association of social risks with health care use among patients with complex multimorbidity.

Design, Setting, and Participants

This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control).

Exposure

Social risks (eg, requiring medical financial assistance and self-reported social barriers to care).

Main Outcomes and Measures

Inpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024).

Results

The sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks.

Conclusions and relevance

In this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

Characteristics of hospital and health system initiatives to address social determinants of health in the United States: a scoping review of the peer-reviewed literature

Background

Despite the incentives and provisions created for hospitals by the US Affordable Care Act related to value-based payment and community health needs assessments, concerns remain regarding the adequacy and distribution of hospital efforts to address SDOH. This scoping review of the peer-reviewed literature identifies the key characteristics of hospital/health system initiatives to address SDOH in the US, to gain insight into the progress and gaps.

Methods

PRISMA-ScR criteria were used to inform a scoping review of the literature. The article search was guided by an integrated framework of Healthy People SDOH domains and industry recommended SDOH types for hospitals. Three academic databases were searched for eligible articles from 1 January 2018 to 30 June 2023. Database searches yielded 3,027 articles, of which 70 peer-reviewed articles met the eligibility criteria for the review.

Results

Most articles (73%) were published during or after 2020 and 37% were based in Northeast US. More initiatives were undertaken by academic health centers (34%) compared to safety-net facilities (16%). Most (79%) were research initiatives, including clinical trials (40%). Only 34% of all initiatives used the EHR to collect SDOH data. Most initiatives (73%) addressed two or more types of SDOH, e.g., food and housing. A majority (74%) were downstream initiatives to address individual health-related social needs (HRSNs). Only 9% were upstream efforts to address community-level structural SDOH, e.g., housing investments. Most initiatives (74%) involved hot spotting to target HRSNs of high-risk patients, while 26% relied on screening and referral. Most initiatives (60%) relied on internal capacity vs. community partnerships (4%). Health disparities received limited attention (11%). Challenges included implementation issues and limited evidence on the systemic impact and cost savings from interventions.

Conclusion

Hospital/health system initiatives have predominantly taken the form of downstream initiatives to address HRSNs through hot-spotting or screening-and-referral. The emphasis on clinical trials coupled with lower use of EHR to collect SDOH data, limits transferability to safety-net facilities. Policymakers must create incentives for hospitals to invest in integrating SDOH data into EHR systems and harnessing community partnerships to address SDOH. Future research is needed on the systemic impact of hospital initiatives to address SDOH.

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), (2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

BACKGROUND

Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services.

OBJECTIVE

Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area.

DESIGN/PARTICIPANTS

Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services.

INTERVENTION

SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT).

MAIN MEASURES

HbA1c, blood pressure, and LDL over time for each study group.

KEY RESULTS

Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05).

CONCLUSION

The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy

This paper shares lessons learned from providing planning and technical assistance to the grantees of the Merck Foundation's 5-year, $16 million initiative, Bridging the Gap: Reducing Disparities in Diabetes Care, designed to improve access to high-quality diabetes care and reduce disparities in health outcomes among vulnerable and underserved U.S. populations with type 2 diabetes. Our objective was to co-create, with the sites, financial sustainability plans to sustain their work once the initiative had ended and to improve and/or expand it to serve more patients, better. Financial sustainability is an unfamiliar concept in this context, largely because the current payment system inadequately compensates providers for the value their care models provide to patients and to insurers. Our assessment and recommendations are based on our experiences working with each of the sites on sustainability plans. The sites were diverse in terms of their approaches to clinical transformation and integration of SDOH interventions, geography, organizational context, external environment, and populations served. These factors influenced the sites' capacity to build and implement viable financial sustainability strategies and the eventual plans themselves. Philanthropy has a critical role in investing in providers' capacity to develop and implement financial sustainability plans.