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Assessing Social Drivers of Health: Why Healthcare is Focusing on Social Needs—and How It Could Change Your Care



Healthcare isn’t just about what happens inside a doctor’s office. It also goes beyond your genetic coding and family history. Social factors like where you live, if you have access to healthy food, and a support system play a significant role in your overall health and well-being. Recognition of these social factors and their role in the healthcare landscape has led to the needed shifts that will help improve long-term outcomes. 


In this article, we’ll dive into the concept of Health-Related Social Needs (HRSN), explain why healthcare is paying attention to them, and explore what’s being done to improve care. 


What Are Health-Related Social Needs (HRSN)? 


Health-Related Social Needs (HRSN) are factors outside of traditional medical care that influence a person’s health. These include: 


  • Housing stability (having a safe place to live) 

  • Food security (access to healthy, affordable food) 

  • Transportation (getting to doctor’s appointments) 

  • Social support (having family or friends to lean on) 

  • Access to utilities (electricity, water, heat) 


While doctors can’t “treat” these social issues, they’re strongly connected to how well people can manage their health. For example, if someone doesn’t have a stable home or can’t afford groceries, managing chronic conditions like diabetes or heart disease becomes much harder. Furthermore, the stresses that come with financial strain can exacerbate these conditions. 


Why Is Healthcare Paying Attention to Social Needs? 


So, why are healthcare providers suddenly focusing on social needs? The short answer: it makes a big difference to patients’ health and improving outcomes helps reduce costs. 


  1. Better Health Outcomes 

    Research shows that up to 80% of health outcomes are influenced by social factors, not just medical care (Berkowitz, S. A., et al., 2018). For instance, someone who doesn’t have stable housing or access to healthy food may struggle to manage chronic illnesses, which could lead to more frequent hospital visits and complications. 


    By addressing social needs, healthcare providers can help patients stay healthier in the long run, reducing the need for emergency care. This is particularly important as the U.S. Health in International Perspective report highlights that social factors, including income inequality and lack of access to healthcare, play a substantial role in poorer health outcomes in the U.S. compared to other high-income countries (National Research Council, 2013). 


  2. Reducing Healthcare Costs 

    The exorbitant costs associated with U.S. healthcare have long been a pain point for many Americans. A large portion of these costs comes from hospital readmissions and emergency room visits—many of which could be prevented by addressing social factors. For government programs like Medicare and Medicaid, which cover millions of low-income Americans, addressing social needs can help reduce costs by avoiding expensive medical treatments down the road because stable conditions mean that patients are more likely to attend doctor’s appointments and follow treatment plans. 


What Is Healthcare Doing About It? 


The good news is that healthcare systems are already taking action to address these needs. Here’s how they’re responding: 


  1. Funding and Support 

    In the U.S., Medicare and Medicaid provide funding for healthcare, and much of this money flows through Managed Care Organizations (MCOs). These organizations are now being encouraged to address social factors in their care plans. For example, they might help patients access food programs or connect them to housing support. 


  2. Value-Based Care: Paying for Outcomes, Not Just Services 

    One of the biggest changes in healthcare is the shift from fee-for-service (where providers get paid for every test or procedure) to value-based care (where they’re paid based on the health outcomes they deliver). This new model encourages healthcare providers to focus on preventing illness, improving patient satisfaction, and reducing unnecessary hospitalizations. By helping patients address social needs, providers can improve health outcomes, reduce costs, and get better results for patients. For example, helping a diabetic patient with transportation to appointments can prevent complications that might otherwise lead to costly hospital stays. 


  3. Federal Guidelines and Future Expectations 

    The federal government has started to require healthcare systems to take social factors into account. By 2030, providers will be required to have programs in place that address Health-Related Social Needs as part of their care. This push is aimed at improving: 

    • Better patient experience: When patients have access to the support they need, they’re more likely to be satisfied with their care. 

    • Better health outcomes: Patients are healthier when their social needs are met. 

    • Lower costs: Preventing health problems before they become emergencies reduces overall healthcare spending. 


What’s Working, and What’s Next? 

Some healthcare programs are already seeing positive results from focusing on social needs. For instance, health systems are partnering with local food banks, housing organizations, and community groups to provide patients with the resources they need to stay healthy. But this shift is still in its early stages, and healthcare systems are learning what works best. There’s no one-size-fits-all solution, but a growing body of evidence is showing that when social needs are addressed, health outcomes improve, and costs go down. 


 

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