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The Role of Social Determinants of Health: 

Perspectives from the Healthcare Sector

Lori Peterson

Collaborative Consulting
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Impact of Social Determinants 

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Sources: Feeding America (2016), Map the Meal Gap (2014), and Hunger in America (2014)
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Changing Healthcare Landscape 

From More is Better to Better is Better

From Organizational Incentive to System Incentive 

From My Patient to Our Population

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Changing Healthcare Landscape 

 Healthcare providers increasingly confronted with

• Declining income

• Threat of financial penalties

• Financial rewards

 Sickest 5% of patients account for 50% of healthcare costs

 Significant savings linked to addressing social determinants of health

 80% of health outcomes related to factors outside of clinical healthcare
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Momentum is Gaining 

Increasing Accountability

Population Health Shift

Focus on Needs of Whole Person

Social Determinants of Health

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Social Determinants: Increasing Awareness 
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Not on WHY but...

Examples of WHAT + HOW

More Focus Needed 

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A hospital partnered with a CBO on a 

short-term respite program to achieve:

85% Readmission Reduction for Respite 

Participants

2 Week Reduction in Average Length of 

Stay for Participants

Serving over 200 Homeless Patients 

Annually

Snapshot of Successful Partnerships 

50% Reduction in Total Cost of Care per 

Member per Month

60% Reduction in Hospital Average 

Length of Stay

95% Retention Rate in Community 

Placement at 6 Months

A health plan engaged a CBO to create a 

transitions program achieving:
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A hospital partnered with a CBO to 

implement a food prescription program:

Readmission reduction achieved for 

recipients

Medically tailored meals provided postdischarge

Serving at least 40 individuals a month

Snapshot of Successful Partnerships 

Details:

 Hospital launched a pilot program 

in partnership with CBO

 Sought to reduce readmissions 

and post-discharge complications

 Hospital paid for the costs of the 

meal

 Meal selection based on diagnosis 

and provided for at least 2 weeks

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ProMedica’s Food Pharmacy

• Food bank located on hospital campus fills food prescriptions for families in need 

Connecticut Mental Health Center’s Better Eaters Club 

• Nutritional counseling and cooking classes to improve diets and nutrition of individuals

Hennepin County Medical Center’s Summer Meals Program

• Meal service site providing children free breakfast and lunch daily

Initiatives Focused on Food Insecurity 
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Example Health System’s Perspective 

 East Coast healthcare provider 

 Recognized potential in partnering with community based organizations

 Identified 3 key areas of focus based on needs of population served and related impact 

on health outcomes:

 Food insecurity

 Housing

 Care Management

 Working to assess readiness of CBOs to develop network of strong partners

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Continued 

 Assessing 7 key elements, including:

 Data/Information Sharing Capabilities

 Leadership and Governance

 Organizational Culture

 Evidence-Based Programming

 Quality Improvement Efforts

 Financial Stability

 Operations

 Conducting thorough self and consultant assessments to analyze individual, and 

collective, organizational readiness to identify a network of CBOs to enter contractual 

agreements
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Flounder vs. Flourish Factors 

Leadership

Relating

Trust

Influence

Power

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Today 

 Explore the potential of better addressing social determinants of health through 

cross-sector partnerships

 Incorporate tools and resources that will guide and accelerate efforts in 

collaborating

 Learn from the experiences of others
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Lori Peterson

Collaborative Consulting

lori@collaborativeconsulting.net

866.332.3923