Closing the Health Equity Gap Through SDoH Partnerships



How partnerships between healthcare and community-based organizations can address SDoH and drive better health outcomes 

In the last few years, the phrase “your zip code matters more than your genetic code” has floated around the healthcare industry and with sound reasoning too. In cities across the U.S., the average life expectancy is 15-20 years shorter in low-income communities than those in more affluent communities. Rates of preventable, chronic diseases are rising sharply in low-income neighborhoods, and health gaps between low-income and affluent communities continue to widen. These disparities in health are founded on a complex interplay of racial, economic, educational, and other social factors. But by partnering with community-based organizations (CBOs) to address the social determinants of health (SDoH), healthcare organizations can improve health outcomes in their communities.

Disadvantages facing low-income communities

Studies have shown that Americans at all income levels are less healthy than the income level above their own, and those with incomes that fall into the highest levels of poverty have the worst health outcomes. A study by the Centers for Disease Control and Prevention shows that poor adults are almost five times as likely to self-report being in fair or poor health than adults with incomes 400 times or more than the federal poverty level (FPL), which was $23,825 for a family of four in 2014. The study also revealed that people with incomes that fall into the $35,000 per year and under income level are more likely to have a chronic disease than any other income level. The same study also shows that 8.1 percent of people who fell into this category suffered from coronary heart disease compared to 4.9 percent of people with over $100,000. The individuals who fell into that low-income category had the worst health outcomes than all other income level categories across various chronic diseases and illnesses, including strokes, diabetes, chronic arthritis, hearing, vision, and teeth loss, chronic bronchitis, and more.

How SDoH partnerships can help

The health disparities between low-income and affluent communities are stark, but healthcare organizations have started to address these inequities and are seeing improved health outcomes. The Good Samaritan Health Center, a local community health center in Atlanta’s Westside, recently revealed a 13-year disparity in life expectancy between residents in Atlanta’s Westside and those who live in the more affluent communities nearby. As a response, the Good Samaritan Health Center launched the “13 Years” initiative to improve community health and narrow the life expectancy gap. The “13 Years” initiative comprises several strategic partnerships with CBOs and foundations, including the YMCA and the Home Depot Foundation. The organizations within the initiative work together to improve access to healthy food, housing, and green spaces. By establishing SDoH partnerships with CBOs, the Good Samaritan Health Center has been able to link their patients to necessary services and resources like medical care, dental care, behavioral health services, health education, and healthy tools

Reducing costs of care by addressing SDoH

The “13 Years” initiative is just one example of how healthcare organizations and CBOs can improve health outcomes outside of the clinical setting. These partnerships not only improve health outcomes for low-income, at-risk patients, they also reduce the costs associated with care.

For example, in 2017, Reading Hospital partnered with Healthify to help identify and address the social needs of their Medicaid and Medicare populations. The partnership's initial results are promising— in just one year, unnecessary emergency department visits declined by 15 percent, and according to preliminary estimates, the cost of unnecessary visits decreased by as much as $1 million — a 15 percent decrease in just one year.**

A zip code should not determine one’s health. By partnering with CBOs, healthcare organizations are one step closer to ensuring that every individual and family within their communities have an equal chance at better health outcomes. Learn more about developing partnerships with CBOs with our latest white paper, Establishing SDoH Partnerships with Community-Based Organizations. In this white paper, we explore best practices for cross-sector partnerships and the key components needed to drive effective partnerships with CBOs.

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* The project described is supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Results are based on Reading Hospital’s interpretation of internal metrics and are not drawn from the AHC data alone. The research presented here was conducted by the awardee. Findings may not be consistent with or confirmed by the findings of the independent evaluation contractor.

Topics: social determinants of health white paper

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