Health Center 101 Resources: Social Determinants of Health

Medicaid SDOH Action Plan: Maternal health, behavioral health, family planning, managed care (2023). Resource Type: Publication. Description: This short document will provide guidance to assist health centers to better serve their patients by highlighting Medicaid reimbursable services that address social drivers of health (SDOH) and guidance to assist health centers in obtaining payment for SDOH-related services. More Details...

SDOH 2: Housing is Healthcare: Stable Housing Creates Positive Health Outcomes (2021). Resource Type: E-Learning. Description: Health Centers have a role forging relationships with community partners to help stabilize patients' housing which in turn has been demonstrated to improve health outcomes. More Details...

Social Determinants of Health (SDOH) Hub (2022). Resource Type: Toolkit. Description: The SDOH Resource Hub provides health centers (HCs) access to available screening tools, educational materials such as guides, fact sheets, infographics, videos, and other resources related to the social factors that affect people’s health, to assist staff efforts in screening, documenting, and addressing SDOH factors impacting the MSAW population. More Details...

Incorporating Social Determinants of Health (SDOH) Data into Risk Stratification Models to Improve Health Equity – Webinar (April 2021) (2021). Resource Type: Archived Webinar. Description: AAPCHO hosted the Incorporating Social Determinants of Health (SDOH) Data into Risk Stratification Models to Improve Health Equity webinar. In this webinar, participants gained in-depth knowledge about the foundations of risk stratification through findings from the 2019 PRAPARE Risk Stratification Learning Collaborative. Health center staff and AAPCHO facilitators provided context and promising practices from a national and local perspective. More Details...

Understanding and Applying SDOH Screening Data to Address Barriers to Health: Webinar (2021). Resource Type: Archived Webinar. Description: Health centers provide high-quality primary and preventive care to diverse populations in special and vulnerable populations in underserved communities. Health centers also provide a host of enabling services – non-clinical services that aim to increase access to health care and improve population health outcomes. The ability to track and evaluate these services is an important tool for health centers to demonstrate their value in addressing patients’ social determinants of health; of equal importance is the ability to make this data actionable in order to address patients’ barriers to access. More Details...

Understanding Social Determinants of Health: Back to the Basics on the factors that impact health outcomes (2020). Resource Type: Archived Webinar. Description: This webinar highlights its not just the care received in the clinic. In reality the health outcomes are impacted by services throughout the community. Community partnerships are essential to leverage the resources to meet needs. More Details...

Two Sides of the Same Coin: Addressing Social Determinants of Health and Enabling Services Data Collection (2019). Resource Type: Archived Webinar. Description: As health centers are held accountable for cost containment and high quality of care under value-based pay arrangements, it is increasingly important for providers to document the social determinants of health (SDoH) barriers of their patients and what services they are providing (both clinical and non-clinical) in order to properly care for those complex patients. Some of these services are called enabling services (ES), defined as non-clinical services that aim to increase access to care and improve health outcomes. Standardized data collection on SDoH and ES are two sides of the same coin and provide the foundation for health centers to succeed in a value-based pay environment. This not only helps them address root causes of poor health, but also highlights the value of the health center model. More Details...

Why Collect Standardized Data on Social Determinants of Health?: A slide deck outlining the potential use of ICD10 coding for SDOH. (2017). Resource Type: Publication. Description: This resource will equip health center stakeholders with the motivation, knowledge, and ability needed to collect and use standardized social determinants of health data. This resource describes the importance of collecting Standardized SDOH Data in the context of value based payment.  The resource reviews commonly used codes in ICD-10 that can help document SDOH.  Finally, the slide deck describes useful tools for collecting these data and what’s on the horizon for health centers to strengthen their efforts to move “upstream” in addressing health disparities. Download this slide deck below. More Details...

Population Health Management, Social Determinants of Health and How These Fit: The relationship between population health management and social determinants of health (2016). Resource Type: Publication. Description: This is a 21-slide module presenting an introduction to the concept of and relationship between population health management and social determinants of health beginning with current definitions, a brief history of along with the evolution of the field. This is a 21-slide module presenting an introduction to the concept of and relationship between population health management and social determinants of health beginning with current definitions, a brief history of along with the evolution of the field. A comprehensive model for the relationship among the social determinants of health and outcomes of population health is also included. More Details...

Emerging Issues in Payment Reform: Engagement at the State Level and Opportunities to Address the Social Determinants of Health (2017). Resource Type: Archived Webinar. Description: This webinar focuses on the national and state payment reform landscapes and its administrative changes to explain how they are used in different states and why. It also details how some health centers document social determinants of health (SDOH), and how this could influence delivery system reform. Lastly, It highlights different strategies and tools health centers could use to connect with key players on the state levels. More Details...

Coding Social Determinants of Health (SDOH) for Optimizing Value: An Infographic for Providers on the Benefits of Coding for SDH (2017). Resource Type: Publication. Description: The purpose of the infographic is to describe how SDH data would be used for a variety of goals that would have traction with the clinic staff audience who may likely need to modify workflows and behavior in order to collect such data.  The visual case could be used in presentations or hung on a provider break room wall. SDH coding is important for clinical management and outcomes reporting for payment reform and value based payment (particularly capitate payment), as well as other policy work. SDH coding begins with care providers, who often may need to understand how these data can be used to benefit not only the patient they are serving but also the broader population served by the organization. More Details...