Community-Level Actions On The Social Determinants Of Health: A Typology For Hospitals

Health in the United States is not equally distributed; there is a 15-year gap in life expectancy between the richest and poorest 1 percent of Americans. There is clear evidence that health and health inequities are largely determined by the conditions in which we are born, grow, live, work, and age—the social determinants of health (SDOH). These include education, employment, income, and housing and are in turn shaped by systems that maintain unequal power and privilege, including institutional and structural racism.

In the past decade, interest in SDOH among health care leaders has grown rapidly, and there is an increasing focus on the role that health care can and should play in responding to social needs and tackling SDOH. This has been heightened by the unequal impact of the COVID-19 pandemic and the national social movement for racial equity following the murder of George Floyd.

Health care organizations can act on SDOH at two levels: at the individual patient level and for wider communities, in which beneficiaries include those who may not be patients of the organization. Much of the interest, action, and academic study to date has been on the former, such as through an emphasis on patient-level social screening and referrals to social services. However, sustained improvement in the SDOH is likely to require community-level change. The importance of this work has been emphasized by several national organizations, including the American Hospital Association, America’s Essential Hospitals, and the Association of American Medical Colleges.

In addition, as the federal and state governments increasingly incentivize action addressing patients’ social needs, acting at a community level to reduce social needs and improve social service capacity may be increasingly beneficial for health organizations. For instance, in August 2022, the Centers for Medicare and Medicaid Services finalized a rule requiring that starting in 2024 hospitals report social-risk screening rates as part of the Hospital Inpatient Quality Reporting program. In 2021, half of all states required social-risk screening in Medicaid managed care contracts, and a number are also requiring care management for SDOH including referrals to social services and supports.

Hospitals and health systems (hereafter, hospitals) are already engaged in a range of activities to address SDOH at the community level. However, to date, no organizing framework has been proposed to describe these activities. In this article, we propose a typology that classifies eight key strategies into three categories, loosely defined by different types of activities for different immediate goals. Our hope is that by defining and differentiating hospitals’ community-level SDOH activities and providing a common language, we can help advance practice, policy, and research in this space (see exhibit 1).

Exhibit 1: Typology of community-level actions for hospitals to address social determinants of health

Source: Authors’ own analysis.

1. Leverage Business Operations For Community Economic Development

In the first category of our typology, hospitals direct some of their existing hiring, procurement, and investments toward local underresourced communities to better align their institutional and operational resources with their clinical missions. Popularized as “anchor institution strategies” by the nonprofit Healthcare Anchor Network, this set of strategies recognizes the impact that hospitals can have on local SDOH as businesses and employers with large operational budgets and investment portfolios.

Hire From Local Historically Marginalized Communities

Recognizing the fundamental importance of good quality employment as a key SDOH, some hospitals deliberately target hiring efforts toward local low-income communities with high rates of unemployment. Specific strategies include targeted recruitment campaigns, partnerships with local workforce development community-based organizations, and pre-employment “pipeline” training programs. RUSH University Medical Center, for example, is focusing on employment as part of their anchor strategy, using the fact that they are the largest employer on Chicago’s West Side to increase the proportion of people hired locally and develop local talent. They are also part of a collaborative, “West Side United,” which has a 2030 goal to decrease local unemployment to below 7 percent.

Hospitals are also taking part in activities to act on SDOH for their existing employees by adopting living wage policies to ensure all staff are sufficiently paid or providing career development support, particularly for workers in lower-grade jobs. For example, in 2020, the Henry Ford Medical system increased their minimum wage to a “living wage” of $15, more than $5 above the state minimum wage.

Procure From Local, Historically Marginalized Communities

US hospitals collectively spend more than $340 billion a year on goods and services. As part of anchor institution work, some hospitals are ensuring that a greater proportion of this spending goes toward local small businesses owned by people of color or other individuals who face structural inequities. The Children’s Hospital of Philadelphia’s (CHOP’s) Health Together initiative, for instance, has worked with more than 90 local diverse businesses to help them get certified as minority and women-owned business enterprises (MWBEs). They also provide training and link MWBEs to procurement opportunities. To date, they have awarded $1.6 million in contracts to local, diverse businesses.

Shifting hospital procurement typically involves internal analysis to understand which contracts could be sourced locally, setting organizational targets, building capacity within hospital departments to change suppliers, and both encouraging and supporting small, diverse, local suppliers to apply for hospital contracts.

Invest In Local, Historically Marginalized Communities

Many hospitals have significant investment portfolios, and some are redirecting portions of those investments toward local social needs, such as affordable housing or capital for small local diverse businesses. Investment activities include loans (often administered through local community development financial institutions), as well as loan guarantees. Unlike with grants, loans are returned to the hospital with interest at the end of the loan term. Although the interest rate is generally lower than for other investments, the funds still ideally grow and can be re-invested repeatedly.

The University of California, San Francisco recently launched a community investment program as part of its Anchor Institution Mission. To date, it has loaned $5 million to four financial intermediaries with strong ties to communities that are providing low-interest loans to local minority-owned small businesses and organizations working on local housing assistance, employment, and financial support.

2. Improve Availability Of Local Social Services

The social service sector in the US is underfunded when compared both with the health care sector and with social spending in other countries. This means that communities often lack accessible, high-quality local social services and resources that can positively impact community-level SDOH. The second category of activities comprises strategies adopted by hospitals to help ensure needed social services and supports are available locally. Strategies include grants, non-financial support, and direct provision of services.

Fund Services Through Grants

Most hospitals provide grants to local community-based organizations. At not-for-profit hospitals, this usually forms part of the “community benefit” they are required to report on to maintain their federal tax-exempt status. Although most hospital grant programs have historically focused on health promotion efforts such as tobacco cessation or nutrition education, grants can also be targeted further upstream to help address the community’s social needs by funding social services and programs such as educational services, youth services, workforce development, food banks, eviction prevention services, among many others. As an example, Hawaii Pacific Health’s community benefit program works with community partners to create opportunities for better health by investing in housing stability, food security, economic empowerment, and education, and has provided grant funding to a nonprofit that provides loans and financial counselling to low- and moderate-income households that lack access to mainstream financial services.

Provide Non-Financial Support

Hospitals also have significant non-financial resources that can benefit local social-sector organizations providing essential SDOH services or programs. These include staff time and expertise (for example, grant writing, research methods, program development, lobbying, marketing), data, and land and buildings. By sharing these resources with local social service organizations, hospitals can support and contribute to a thriving local social care infrastructure, without (or in addition to) giving out grants. For example, Nationwide Children’s Hospital enables their staff to support community SDOH-related services, including their in-house attorneys assisting the medical-legal partnership Lawyers for Kids.

Directly Provide Services Or Resources

Hospitals can also provide social services themselves when there is an identified gap in local service provision, and it makes sense for the hospital itself to provide the service. For example, Franciscan Missionaries of Our Lady Health System in Baton Rouge, Louisiana, set up an ethical pay-day loan company for their employees. It has recently been extended to also serve local community members. Promedica, an integrated health system in Ohio and Michigan, established and runs a supermarket in a community that was previously a food desert. This type of action may involve partners, but unlike grant-giving, the hospital is involved in running the service.

3. Advance Systems And Policy Change

The final category includes strategies that hospitals are adopting to produce systems and policy change, with the aim of influencing community-level political, economic, and social contexts. There are two strategies in this category: coming together with other organizations to achieve local systems change through a collective impact around a shared issue (multisector coalitions) and the more expansive systems change achieved through policy advocacy.

Support And Engage In Multisector Coalitions

In response to the complex, multifactorial nature of SDOH issues, some hospitals have either joined or established multisector coalitions—formalized collections of organizations working together, often using collective impact approaches. Multisector coalitions can be aligned around a geographical place, a section of the population, a particular SDOH issue, or a combination of these. Activities include aligning organizational action to reduce duplication and to amplify previously siloed efforts, sharing learning and data, and setting up shared systems of accountability to achieve a mutual aim or vision.

All Children Thrive, for example, is a collaborative established by Cincinnati Children’s Hospital aiming to help Cincinnati’s children be the healthiest in the nation. Partners work together to achieve shared goals. Successes to date include reduced infant mortality and excess days spent in hospital, improved access to preventive services, and increased childhood literacy outcomes.

At times, organizations within multisector coalitions may take part in other strategies described in this article. They may provide each other with technical assistance (non-financial support), pool funding for shared projects (investment or grants), or work together on policy change efforts (advocacy).

Support And Engage In Advocacy

Health and health inequities are not just a product of organizational activity, they also are shaped by policies and laws. Hospitals, therefore, have sometimes used their social and political capital to advocate for changes to policy or funding structures related to SDOH at the local, state, or federal levels.

Hospitals can take part in advocacy directly, fund partner organizations for specific advocacy activities, or lend public support to advocacy campaigns to help add weight and focus on the potential health impacts of policy change.

For example, Cone Health, in Greensboro, North Carolina, partnered with community stakeholders to advocate for municipal enforcement of healthy housing ordinances in multi-unit apartment complexes. Boston Medical Center, Boston Children’s Hospital, and Brigham and Women’s Hospital created the Innovative Stable Housing Initiative, which, alongside other activities, funds local organizations to work to change housing policy, including anti-displacement, tenant protections, community control of land, and asset building.

Conclusion

Our typology differentiates between categories of hospital-led community-level SDOH activities. Firstly, hospitals can leverage core business activities to advance community economic development by shifting hospital employment, procurement, and investment. Secondly, they can support local social service infrastructure through grants, non-financial resources, and direct service provision. And finally, they can create systems and policy change by taking part in multisector coalitions and advocacy.

Although these activities can overlap, they are often undertaken independently by different parts of the organization. Ideally, hospitals will increasingly find ways to ensure that strategies inform and complement each other—for example, a hospital may be part of a local coalition to tackle youth unemployment (Category 3) and based on this, provide grants to a local community-based organization providing training programs (Category 2), and then link trainees from this program to job opportunities in their own organization (Category 1).

As this emerging area of practice advances, hospitals face several key challenges, including convincing hospital leaders to invest resources in this work and learning how to effectively implement activities such as community development that may be new to the organization. As many hospitals are partly funding SDOH work from external sources—including philanthropic, state, or federal grants—it is also important to ensure that increased involvement by hospitals in community-level SDOH initiatives does not divert funding or focus from existing SDOH-focused community-based organizations or efforts. Hospital efforts related to SDOH should supplement, not supplant, existing efforts.

It is also essential to ensure that community-level SDOH work contributes to community health equity. This will likely require embedding explicit equity goals in SDOH activities, meaningfully involving local communities in designing, delivering, and evaluating community-level interventions, and ensuring that community strategies are tailored to local needs and assets.

Finally, future evidence on the comparative impacts of different strategies will ideally support refinement, spread, and scale of these activities in ways that contributes to positive and equitable community health impacts. In the meantime, we hope that the common language and examples provided in this typology help organizational leaders, policy makers, and researchers think more comprehensively about efforts to improve SDOH at the community level in ways that will accelerate learning and impact in this rapidly expanding field.

Author’s Note:

Support for the research conducted by Matilda Allen was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.