There are a number of efforts occurring across the country to help address social determinants. Initiatives and models have developed at the local, state and federal levels and have leveraged delivery system or value-based payment models.

Additionally, many private sector entities are taking innovative steps to address social determinants, whether by funding referral and coordinating services, helping to develop and integrate community service networks, and deploying community health workers, among other strategies.

In the following sections, we describe some of the innovative efforts being made at the local level as well as in the private sector.

Innovative Local Examples

Hennepin County, MN – Hennepin Health

Hennepin Health is a Medicaid Accountable Care Organization (ACO) based in Hennepin County, Minnesota that began integrating the delivery of health and social services to a subset of the county’s Medicaid population in 2012. Hennepin Health began with the goal of increasing the use of preventive care and reducing preventable hospital admissions and emergency department visits by addressing beneficiaries’ other needs alongside their healthcare needs.

The program originally targeted individuals between the ages of 21 and 64 without dependents earning up to 75% FPL who gained coverage under the Medicaid expansion, but has since been expanded to children and families.  Individuals in Hennepin County may choose Hennepin Health as one of their managed care options when selecting a health plan. Hennepin Health is also the default health plan for eligible beneficiaries who do not select a health plan.

Hennepin begins by identifying high-risk members via a Member Lifestyle Assessment.  Those who are deemed high-risk are then sought after by Hennepin Health staff and social workers. High-risk members are then referred to a Coordinated Care Center, which is an ambulatory intensive care unit and provides primary care and behavioral health services through multidisciplinary teams that include a nurse care coordinator, an advanced practice provider, as well as a social worker.

Hennepin Health initially estimated that on average, high-risk members would need to continue receiving care from the Coordinated Care Center for three to six months. However, they have found that patients need more care for longer periods of time before transitioning to their Access Clinic, which provides team-based primary care for patients that are not at high enough risk to be admitted to the Coordinated Care Center.

The ACO also partners with local nonprofits and social service agencies to help its members find housing. The organization has a “housing first” approach, in which it seeks housing for members as its first priority, then begins to work on securing services for mental health, substance use disorder treatment, employment assistance, and other lifestyle health services.

According to a case study by The Commonwealth Fund, after an initial investment by its partners of $1.6 million to build the infrastructure of what eventually became Hennepin Health, the ACO has saved money each year. In fact, medical costs have decreased by roughly 11% per year since 2012.

As part of Hennepin Health’s shared savings model, it distributes a portion of the savings to each of its partners based on their respective involvement in members’ care and completion of performance benchmarks.

Per the Commonwealth Fund case study, after distribution, over 2013, 2014, and 2015, the organization had about $3 million left to reinvest into the program. These reinvestments include hiring additional community health workers, hiring a part-time psychiatrist, and other initiatives. As a result of the program, ED visits decreased by 9.1% between 2012 and 2013, and outpatient visits increased by 3.3%. According to a Hennepin Health report, members who had been placed in housing were admitted to a hospital 16% less often, visited the ED 35% less often, visited the psychiatric ED 18% less often, and received outpatient clinic visits 21% more often between 2012 and mid-2014.

Additionally, a recent Health Affairs study of Hennepin Health sought to assess the correlation between individuals who are high-cost, high-need healthcare users and those who are also frequent users of other social services.

The authors found that over three-quarters of Hennepin Health’s Medicaid beneficiaries who are high utilizers (defined here as those with at least four emergency department visits or at least three inpatient hospital stays per twelve months of Medicaid enrollment), were diagnosed at least once with mental illness, substance use disorder, or both.

Additionally, 96.7% of high utilizers used human services at some point during the study period, compared to roughly three-quarters of the other enrollees. 94.5% of high utilizers used food support services, and about 70% used general assistance income support. Further, high utilizers accounted for expenses over four times higher than those of other enrollees in terms of per capita direct public spending. In all, the study points to the fact that a coordinated, integrated approach to addressing social determinants may help to improve outcomes.

Hennepin Health was established through a formal collaboration between Hennepin County Medical Center, NorthPoint Health and Wellness Center, Metropolitan Health Plan, and the Human Services and Public Health Department of Hennepin County. Hennepin Health has helped coin the term “totally accountable care organization” through its efforts to integrate physical, social, and behavioral health care delivery and data.

The four organizations collectively form Hennepin Health; the organizations share full (two-sided) financial risk for their enrolled beneficiaries. Hennepin reimburses contracted medical providers for care delivered to its members, and also contracts with additional affiliated providers for other needs, such as vision, dental, behavioral health, and pharmacy.

Hennepin Health was established through a formal collaboration between Hennepin County Medical Center, NorthPoint Health and Wellness Center, Metropolitan Health Plan, and the Human Services and Public Health Department of Hennepin County. Hennepin Health has helped coin the term “totally accountable care organization” through its efforts to integrate physical, social, and behavioral health care delivery and data.

The four organizations collectively form Hennepin Health; the organizations share full (two-sided) financial risk for their enrolled beneficiaries. Hennepin reimburses contracted medical providers for care delivered to its members, and also contracts with additional affiliated providers for other needs, such as vision, dental, behavioral health, and pharmacy.

See additional resources on Hennepin Health from:

Montgomery County, MD – Healthy Montgomery

Montgomery County developed an initiative in 2009 called Healthy Montgomery. This program’s purpose is to “identify and describe disparities in health status among the County’s communities and populations, identify unmet health needs, develop and implement action plans to meet those needs, and evaluate the effectiveness of the strategies implemented.”

The program implemented a Community Needs Assessment to set healthcare and healthy living county-wide priorities and to develop a Community Health Improvement Plan. Further, the County has invested in comprehensive data collection efforts, allowing it to get a full glimpse of trends in issues like obesity, tobacco use, and poverty.

In 2014, the Healthy Montgomery Steering Committee adopted a set of six Core Measures – behavioral health, cancers, cardiovascular health, diabetes, maternal and infant health, and obesity. These data are used to compare the overall health metrics of Montgomery County to those of other counties in the state of Maryland, as well as to national statistics. The Core Measures are also used to track Montgomery County’s progress in benchmark programs such as Healthy People 2020 and the Maryland State Health Improvement Process.

Montgomery County has also invested in developing and maintaining a fully integrated data system, which allows county workers to see a full picture of the services in which consumers are enrolled. This system allows county officials to see which consumers are eligible for certain services but are not enrolled, allowing for the opportunity for county officials to reach out and ensure that consumers in need are enrolled in services that they are eligible for.

About 60% of the funding for Montgomery County’s program comes from local taxes, but that money is braided with federal funding, which is used to administer programs such as TANF, SNAP, and others. The annual budget is $318 million.

Additionally, Healthy Montgomery utilizes public/private partnerships with area health systems and public health entities, such as Holy Cross Health and the Institute for Public Health Innovation, to award grants to firms that can help the County develop nutrition promotion, tobacco prevention, and other policy, systems, and environmental change strategies.

Montgomery County incorporates an integrated Health and Human Services Department, which administers a “birth to death” suite of services, including housing, homeless, health, and mental health. This structure helps county officials better understand, address, and track progress on cross-sector issues, and to implement a Health in All Policies Model of policymaking.

San Diego County, CA – Live Well

In 2010, San Diego County adopted a ten-year public health initiative called Live Well, designed to “align the efforts of individuals, organizations and the government to help all 3.3 million San Diego County residents live well.”

The county has taken steps to collaborate with community-based partners and individuals to support its vision in Building Better HealthLiving Safely, and Thriving.

It has taken steps to Build Better Health by addressing three main issues that the County believed to impact 50% of medical costs: smoking, unhealthy eating, and a sedentary lifestyle. The county has supported initiatives to improve access to quality care, increase physical activity, support healthy eating, and stop tobacco and other drug use.

Live Well promotes Living Safely by taking steps to ensure that they are protected from crime or abuse, that neighborhoods are safe to work, live and play, and that communities are resilient to disasters and emergencies in order to promote a positive, safe environment. The program aims to achieve these goals by fostering commitments between social service and criminal justice agencies to work together to develop and implement strategies that enhance public safety.

Finally, the county focuses on building community awareness and connectivity, filling gaps and ensuring equal access to basic needs, and helping residents to improve their literacy and to connect with employment opportunities – allowing residents to thrive. Live Well plans to fulfill these goals by connecting seniors and people with disabilities with accessible housing, increasing access to the internet, and expanding after-school programs.

In an effort to efficiently integrate data collected by various departments, Live Well compiles hospital admission, public health, behavioral health, and injury data into a portal which can be sorted by region, socioeconomic status, year, age, sex, and many other criteria.

The program also has webpage dedicated to displaying results as they pertain to Live Well’s indicators of interest – health, knowledge, standard of living, community, and social. These charts and graphs show year-by-year trends in life expectancy, unemployment, income, crime, and community involvement.

Both of these initiatives illustrate Live Well’s will to be transparent and hold themselves accountable.

Funding for the program began in 2010, when the County received a $16 million Communities Putting Prevention to Work (CPPW) federal grant, as well as a five-year grant from the CDC National Public Health Improvement Initiative. In 2011, the program received an additional five-year, $15 million Community Transformation Grant.

Such grant funding, along with county funding, helps Live Well utilize community workers and other types of navigators to provide consumer assistance. Since the program utilizes both local and grant sources of funding, funding is braided through various sectors of the initiative.

Unlike some of the other examples of county-based efforts to address social determinants we have highlighted here, Live Well focus is not on delivery, but on policy. The county did not establish a formal shared savings or value-based care structure, such as an accountable care organization or accountable health organization, nor is Live Well specifically focused on the low-income, or Medicaid, populations. Instead, it is an all-encompassing effort to redirect policy priorities and county-funding, and to work with community partners, towards improving whole-person health and wellbeing.

Such a cross-sector effort was made possible by the Country’s unique operations and governance structure. After the passage of welfare reform in the 1990s, San Diego County integrated its health, human services, veterans services, aging, and children’s services, among others, into one comprehensive Health and Human Services Administration. The consolidation of these departments allowed the county to create shared measures of success, as well as to implement integrated IT systems to easily share data between programs.


National Academy for State Health Policy -NASHP, “Blending, Braiding & Block-Granting Funding for Public Health and Prevention: Implications for States.”

  • Issue brief developed in collaboration with the de Beaumont Foundation and the Association of State and Territorial Health Officials, which provides analysis and recommendations for states interested in coordinating services and resources across programs.

NASHP, “Braiding the Blending Funding Streams to Meet the Health-Related Social Needs of Low-Income Persons: Considerations for State Health Policymakers.”

  • Issue brief highlights non-Medicaid funding sources that states could leverage through braiding or blending to better address social determinants or other needs that are not typically addressed by Medicaid.

Center for Health Care Strategies, “State Payment and Financing Models to Promote Health and Social Services Integration.”

  • Issue brief reviews several financing mechanisms for states considering greater health and human service integration, with a focus on Medicaid. Suggested models described range from one-time seed funding to broader braiding and blending strategies. The brief also summarizes ways that states can better encourage providers to incorporate social services into their care.

Milbank Memorial Fund, “Medicaid Coverage of Social Interventions: A Road Map for States.”

  • Issue brief developed in coordination with the Reforming States Group and the New York State Health Foundation, which provides a guide for states in understanding how to leverage current Medicaid flexibility to facilitate access to social services.

Commonwealth Fund, “A State Policy Framework for Integrating Health and Social Services.”

  • Issue brief describes three components that states must implement in order to integrate health and social services: a coordinating mechanism, appropriate quality measurement and data-sharing tools, and aligned financing and payment procedures.

Commonwealth Fund, “Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case.”

  • Issue brief describes examples of private sector investments in social determinants of health as a key part of healthcare business operations.

McKinsey & Company, “Insights from McKinsey’s Consumer Social Determinants of Health Survey.”

  • Survey findings shed light on how social determinants of health affect healthcare utilization rates and consumers interest in social program offerings.

Center for Health Care Strategies, “Supporting Social Service Delivery through Medicaid Accountable Care Organizations: Early State Efforts.”

  • Issue brief describes how state Medicaid programs have incorporated social services into Medicaid accountable care organization models.

Health Affairs, “Integrating Medical and Social Services: A Pressing Priority for Health Systems and Peers.”

  • Blog post lists a number of studies related to social determinants, including efforts to better study and understand the role that social determinants play in health outcomes.

Center for Health Care Strategies, “Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons.”

  • Issue brief describes state efforts to collect and use data on social determinants to drive program improvements and strengthen the linkages between health and social service agencies.

National Academy for State Health Policy – NASHP, “Blending, Braiding & Block-Granting Funding for Public Health and Prevention: Implications for States.”

  • Issue brief developed in collaboration with the de Beaumont Foundation and the Association of State and Territorial Health Officials, which provides analysis and recommendations for states interested in coordinating services and resources across programs.

JAMA Network, “Association Between Receipt of a Medically Tailored Meal Program and Health Care Use”

  • In this cohort study of 1020 adults that used a combined instrumental variable analysis and matching approach, participation in a medically tailored meal delivery program was associated with approximately half the number of inpatient admissions.

NASHP, “Federal and State Collaboration to Improve Health through Housing.”

  • Issue brief provides policy recommendations to align health and housing programs to ensure that beneficiaries receive needed housing and supportive services.

NASHP, “Improving Health through Housing: Three Tips for State Policymakers.”

  • Blog post provides three concise recommendations for states to consider that would help to improve health through housing.

Kaiser Family Foundation, “Linking Medicaid and Supportive Housing: Opportunities and On-the-ground Examples.”

  • Issue brief outlines currently flexibilities in the Medicaid program to support supportive housing services, and highlights three initiatives that target special populations including homeless individuals, people with disabilities, and adults with mental health and/or substance misuse disorders.

Center for Health Care Strategies, “Medicaid-Financed Services in Supportive Housing for High-Need Homeless Beneficiaries: The Business Case.”

  • Issue brief describes why states should consider designing Medicaid-financed, supportive housing-based care management services.

Brookings Institution, “Re-balancing Medical and Social Spending to Promote Health: Increasing State Flexibility to Improve Health through Housing.”

  • Issue brief describes some of the evidence supporting initiatives to link healthcare and housing services as well as current federal programs that engage housing to help address health.

Center on Budget and Policy Priorities, “Supportive Housing Helps Vulnerable People Live and Thrive in the Community.”

  • Issue brief describes the importance of supportive housing services, in combination with affordable housing to help vulnerable individuals maintain independence and improve health.

Brookings Institution, “Housing as a Hub for Health, Community Services, and Upward Mobility.”

  • Report describes the way in which housing can impact social determinants, and current efforts and barriers to improving access to affordable, healthy housing for low income Americans. It additionally makes several recommendations, including to improve data collection and use, to improve budget and funding coordination, to allow for experimentation in models, and to strengthen housing and healthcare partnerships.

CMS, “Using Z Codes: The Social Determinants of Health Data Journey to Better Outcomes.” 

  • Graphic outlines five steps for using SDOH Z codes and how doing so can enhance quality improvement initiatives.

Center for Health Care Strategies, “Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations.” 

  • Issue brief reviews key considerations for organizations to consider when seeking to collect and use data on social determinants to improve patient care.

National Quality Forum, “Food Insecurity and Housing Instability Final Report.” 

  • Report provides a framework for state Medicaid programs to use in collecting and using data on social determinants of health in order to address social needs.

HHS Assistant Secretary for Planning and Evaluation, “Status of State Efforts to Integrate Health and Human Services Systems and Data: 2016.”

  • Report finds that in response to federal policy and new funding opportunities aimed at improving efficiency and effectiveness, states worked to strengthen connections between their health and human service programs through increased interoperability and systems integration. About two-thirds of states have integrated eligibility and enrollment systems shared by Medicaid and at least one human service program. Further, the report finds that data sharing across programs is common in most states but often only among programs in the same department or agency.

National Governors Association (NGA), “Improving Human Services Programs and Outcomes through Shared Data.”

  • NGA convened a small group of state and local agency leaders, researchers and other experts to discussed the ways “in which shared data can enhance the effectiveness and efficiency of public programs – for example, by reducing the time and burden of separate intake and enrollment systems; helping agencies better understand client needs, develop appropriate solutions and document outcomes and facilitating research that can inform policy decisions.”

NGA, “Using Data to Better Serve the Most Complex Patients: Highlights from NGA’s Intensive Work with Seven States.”

  • Issue brief notes that “among the most critical elements in providing better care for [complex care patients] are data. Before state leaders can begin to address their super-utilizer populations, they first need to understand who those patients are, how they use the health care system, and how the state might adapt its system to meet patient needs.”

Deloitte Center for Health Solutions, “Social Determinants of Health: How are Hospitals and Health Systems Investing in and Addressing Social Needs?”

  • A survey of 300 hospitals and health systems finds that providers are investing in health-related social needs, and that “80 percent of hospital respondents reported that leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care.” Hospitals are increasingly screening patients and performing interventions, which may be spurred on through the shift towards value-based care.
Current Medicaid Flexibilities