Focus Area: Social Determinants of Health

Overview

Social determinants (or drivers) of health are the conditions in the places where people live, learn, work, pray and play. These factors can affect a wide range of health and quality-of-life outcomes, and addressing SDOH needs with supports such as food boxes, housing vouchers, transportation assistance and other non-clinical interventions can likewise have a significant impact on health outcomes, including:

  • Reducing the risk of acute/emergency health issues, accidents and injuries (e.g. by addressing environmental health risks via mold mitigation or repairing a damaged stairway)

  • Managing existing and/or chronic health conditions to prevent worsening and to address symptoms (e.g. supporting diabetes treatment with healthy foods)

  • Preventing disease, or prevent pre-disease symptoms from developing into full blown conditions (e.g. providing school lunches to support children at risk of food insecurity, or providing transportation to help patients get to medical appointments)

  • Reducing toxic stress that can lead to negative health outcomes (i.e. providing housing support services to a family struggling to afford rent, or providing social supports for an isolated senior)

The WNC HPI is looking for ways to enable WNC residents, especially those in rural areas, to be better able to access reliable transportation, nutritious food, economic opportunities, safe and affordable housing, and other SDOH that can impact their health. SDOH-engaged partners, such as Impact Health (which operates the WNC Healthy Opportunities Pilot), play a key role in helping keep the WNC HPI informed and engaged in SDOH needs and intervention efforts in the region, and in enabling what we learn to be shared back to policy makers, researchers, community-based organizations, health care providers, and community members in the region.

SDOH WORK GROUPS AND PRIORITIES

Healthy Opportunities Pilot Renewal

The Healthy Opportunities Pilots (HOP) are “the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees,” (NCDHHS). The HOP program was originally created and funded via an 1115 Demonstration Waiver for $650 million in Oct of 2018 to run for a period of 5 years in three regions of the state, including WNC.

As of 2024, all 3 NC HOPs were pursuing renewal based on the success of their programs, and in particular the WNC HOP (operated by Network Lead Impact Health) is being lauded as a model for other states considering HOP programs. To support this work, our SDOH workgroup is currently focused on evaluating data to understand and demonstrate the ROI of HOP services in terms of reducing costs to Medicaid and improving health outcomes for beneficiaries of the program, and further integrating SDOH interventions into clinical health practices.

2024-2025 Priorities and Objectives

Short-Term – (a) Supporting HOP renewal by demonstrating and amplifying HOP ROI and complementary information; (b) Identifying gaps and highest impact social services

  • Demonstrate the economic model for ROI

  • Ensure entities in the “audience” (LMEs, PHPs, Medicaid, HSOs, policymakers, insured community members) understand:

    • The value of investing in the broader narrative around the impact

    • The impact of HOPs

    • How HOPs have created partnerships/best practices across HSOs

  • Ensure that community voices/qualitative responses are heard to demonstrate the human impact side of the narrative

Longer-Term – Creating a comprehensive regional strategy to maximize SDOH collaborators with CHWs as part of community and clinically integrated care teams