Evaluating a Population Health Approach to Addressing Social Determinants in the Community

Statement of Problem

Social determinants of health (SDOH), such as food insecurity and unstable housing, can lead to disparities in health outcomes, preventable use of health care services and increased health care costs. A growing body of research, including some of our own here at PolicyLab, suggests that screening to address SDOH within health care settings is a feasible endeavor and can lead to increased overall quality of care. There’s also emerging research that if health systems and community organizations work together to implement interventions, it can lead to fewer emergency department visits and improved health outcomes.   

Despite evidence suggesting that social needs critically impact patients’ capacity to manage their and their child’s health conditions, very few large-scale, collaborative interventions exist that utilize the health care system to connect families to community support services. For those interventions that do exist, we lack evaluations that can help us understand their true impact and inform improvements so all patients can receive care to meet their basic living needs.


Through this project with Intermountain Healthcare, Camden Coalition and the Perelman School of Medicine at University of Pennsylvania, we will evaluate a Utah-based population-level intervention that seeks to improve health outcomes and reduce health care utilization costs by connecting patients with community health workers to address their social needs and support their care coordination. Our mixed-methods approach to evaluate Intermountain Healthcare’s efforts will illustrate how health outcomes and health care utilization are impacted by providing social need resources and supporting patient navigation of the health care system.

We will begin by learning about patients’ experiences with the intervention and how it has impacted their health. By interviewing high-risk patients and those that work with them in the community, we can better understand how the intervention has addressed their medical, social and behavioral needs. We will also work with community stakeholders who are identifying high-risk patients and providing them with care to gain a better understanding of what makes this kind of intervention effective.

In order to evaluate the intervention’s effect on patient-level outcomes such as health care service utilization and costs, we will then work with Intermountain Healthcare to conduct a comparative-effectiveness trial within the communities that received the intervention. Our project will examine how connecting patients with a community health worker impacted not only their own health care utilization and costs, but also that of their family.

Finally, to successfully address SDOH we need to understand how policies and policy change could impact the sustainability of such efforts. PolicyLab, in collaboration with Intermountain Healthcare, Gardner Policy Institute and Leavitt Partners, will work to better understand the policy landscape and best practices for developing and implementing funding for the intervention by conducting interviews with state and federal policymakers and developing an analysis of Utah state policies and practices.

Next Steps

Following our evaluation, we will develop recommendations for improving the effectiveness of screening for SDOH and connecting patients to community support services through Intermountain Healthcare’s intervention. We will then disseminate our research findings and recommendations for policy approaches to strategically targeted audiences who can support efforts to integrate SDOH interventions into clinical practice and finance them with existing state and federal programs.

Ultimately, through this evaluation and partnership, we hope to identify how health care systems can best connect patients to community services that address their social needs. In doing so, our goal is to generate first-of-its-kind knowledge about this kind of large-scale health system intervention in order to create sustainable mechanisms to improve the health outcomes of children and adults by addressing SDOH.

This project page was last updated in November 2019.

Suggested Citation

Children's Hospital of Philadelphia, PolicyLab. Evaluating a Population Health Approach to Addressing Social Determinants in the Community [online]. Available at: http://www.policylab.chop.edu. [Accessed: plug in date accessed here]. 

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