Addressing Social Determinants of Health

Intermountain routinely conducts Community Health Needs Assessments to understand the most pressing local health priorities across our service area. Addressing and investing in social determinants of health was identified as a top priority in all the geographies we serve. Social determinants of health are nonmedical factors that impact physical, mental, and social well-being, and include adequate food, housing, utilities, transportation, and interpersonal safety. These factors impact life expectancy more than medical care and magnify health disparities in marginalized communities. The findings in the Community Health Needs Assessments led us to implement strategies that identify the social needs of our patients and members, help connect those with needs to community resources, and increase community capacity and close gaps in services where needed. In addition, the findings led us to prioritize nutrition security and housing stability as top areas of focus.

Identifying Social Need

At Intermountain we know the value of providing whole person care and were progressive in implementing social need screenings during visits to primary care, emergency services, and now during hospital stays. Recently the government agency that administers Medicare and Medicaid created requirements for hospitals to screen adult patients for social needs. Like all medical information, social needs screenings are considered confidential and patient consent is given prior to connection with community resources.

Understanding the barriers in our patients’ lives allows us to provide comprehensive care and connection to community support. In addition to point of care screenings, we are using social risk prediction data to proactively identify individuals who are experiencing social needs since their last screening or who do not regularly access healthcare. These efforts provide a population health approach to preventive care for our patients and communities.

Coordinated Community Networks

Improving the health of one person requires a community of support. We are working alongside other community organizations to better coordinate the delivery of care across physical, mental, and community-based social services. These coordinated care networks facilitate the connection of patients to community resources and improve coordination across different systems and organizations.

Making Social Care a Routine Part of Health Care

Our goal is to make Social Care as routine as taking a patient’s blood pressure in assessing health. Asking questions about basic life necessities provides the care team an opportunity to connect patients with community resources and having regular conversations about social needs helps build trust and decrease stigma. It also can empower patients who often demonstrate an ability to self-resolve reported needs. Patients have shared how the screening questions trigger a realization of how much help they need and how long they have prolonged asking for it.

Evaluation Reports

The groundwork for Intermountain’s Social Care model was based on a collective community demonstration called The Alliance for the Determinants of Health, which was a three-year project in two Utah counties. To learn more, you can read the Alliance’s evaluation reports:

For additional information, contact Gene Smith.