Apr 26, 2019

Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity

Cara V. James, PhD
Director CMS Office of Minority Health

 Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity

Each April marks National Minority Health Month, providing the opportunity to acknowledge the progress made in reducing disparities, as well as a chance to reflect on what more needs to be done to achieve health equity. Discussions about health equity frequently focus on the important roles that preventive services and care quality have in determining health outcomes. While the care we receive plays an important role, health outcomes may often be driven by the conditions in which we live, learn, work, and play. Individuals with inadequate access to food or stable housing are at greater risk of developing chronic conditions and managing these conditions.  They also face increases to health care costs and services that might otherwise be avoidable. These conditions are known as social determinants of health and minority populations tend to be disproportionately affected by them.

Social determinants of health can include housing, transportation, education, social isolation, and more. These factors affect access to care and health care utilization as well as outcomes. As we seek to foster innovation, rethink rural health, find solutions to the opioid epidemic, and continue to put patients first, we need to take into account social determinants of health and recognize their importance.

Addressing the social determinants of health begins with identifying a patient’s needs and measuring their impact. Organizations may measure these factors using a number of existing tools that can help in the identification process, including:

Examples of Z codes

Z55: Problems related to education and literacy

Z59: Problems related to housing and economic circumstances

Z56: Problems related to employment and unemployment

Z60: Problems related to social environment

Z57: Occupational exposure to risk factors

Z64 Problems related to certain psychosocial circumstances

Z58: Problems related to physical environment


Data collection will help us strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services. We are beginning this effort in several post-acute care provider settings this year by proposing that some data elements be collected on standardized patient assessment instruments. Some of the data elements are derived from questions from the Accountable Health Communities and PRAPARE tools mentioned above.

In an effort to reduce expenditures and improve health outcomes, CMS is testing the Accountable Health Communities Model, which is the first model to include social determinants of health. The model is based on emerging evidence that shows addressing health-related social needs through enhanced clinical-community links can improve health outcomes and reduce costs. The model also helps to foster innovation to support connections between care, food, and housing for patients in need.

Adequately and appropriately addressing social determinants of health will require the efforts of all stakeholders including beneficiaries, community groups, and health care providers. The CMS Office of Minority Health collaborated with the Health Resources and Services Administration Office of Health Equity on an event focused on social determinants of health. Participants heard from renowned speakers on how social determinants influence health outcomes, such as physical and mental health, and major chronic conditions that are more common among racial and ethnic minority groups. 

For more information, please visit: go.cms.gov/omh.


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