Written by Crystal Zuzek

Hospitals see value in addressing social determinants of health to improve the well-being of their communities.

A concept known as social determinants of health, defined by the Centers for Disease Control and Prevention as “conditions in the places where people live, learn, work and play [that] affect a wide range of health risks and outcomes,” is becoming a vital part of mainstream health care. But to achieve sustainable success in addressing Social determinants of health, experts say health systems need to alter the way they view their role in improving the health of their communities.

Freya Spielberg

“Clinicians and hospitals have forever seen the health disparities people experience who have social determinants of health,” said Freya Spielberg, M.D., associate professor in the Department of Population Health at the University of Texas Austin Dell Medical School. “What’s new is really embracing that just taking care of illnesses isn’t adequate. If we really want people to be healthy, we need to identify the social determinants of health getting in the way and have treatments beyond the clinic that address those social determinants.”

Dr. Spielberg said addressing social determinants of health could involve investigating why some patients miss their follow-up appointments or assessing whether a patient faces food insecurity challenges that are contributing to poor health.

“Typically, a no-show patient would just be dropped without exploring or accounting for the real barriers that prevented them from coming to their appointment. Now when you think about the difficulty people have getting to an appointment, it might be that they have no transportation or childcare. Once those barriers are identified, someone scheduling an appointment can ask patients if they need help with transportation or childcare,” said Dr. Spielberg.

Safety Net Solutions

Experts in social determinants of health agree that technology plays a role in making progress in patients’ health care outcomes. In 2012, the Parkland Center for Clinical Innovation began building an information exchange portal that allowed community-based organizations and health systems to share data. Since its inception, more than 1 million services have been documented and more than 215,000 patients have been impacted by a network of six health care systems and more than 100 community-based organizations.

Leslie Wainwright

“Not only has this collaboration connected existing organizations in a new system of community health, it has also changed the way health systems define competitors versus collaborators. Local health systems that may have once viewed each other as competitors have recognized that prioritizing the needs of the community through collaboration makes a stronger impact than any isolated intervention,” explained Leslie Wainwright, Ph.D., PCCI chief funding and innovation officer.

According to Wainwright, PCCI was early in the journey to understand Social determinants of health out of necessity. Parkland treats a unique patient population and has recognized some social determinants of health have a tremendous impact on overall utilization patterns. The hospital system also faces capacity challenges that health systems with other payer mixes don’t encounter.

“Not only has this collaboration connected existing organizations in a new system of community health, it has also changed the way health systems define competitors versus collaborators.”


Parkland treats a population made up of 28% uninsured patients, 32% Medicaid patients, and 17% Medicare patients. The remaining 23% falls into another payer mix, said Wainwright. PCCI’s work on social determinants of health has helped underserved populations in the Dallas area. For example, to reduce adverse drug events, PCCI developed the Patients at Risk for Adverse Drug Events program at Parkland. During its two years of implementation, the PARADE program helped prevent more than 2,000 ADEs for hospitalized patients, resulting in a potential savings of more than $17 million by reducing readmissions and eliminating ADEs. In that time, the program screened more than 87,000 patients and identified 8,731 high-risk patients. Of the high-risk patients, 16% received timely pharmacy intervention, and more than 2,000 ADEs were prevented. For high-risk patients receiving a consult, the 30-day readmission rate was cut by 23.5%. The program’s accuracy and efficiency have made it a daily standard practice, according to PCCI.

PARADE screens all adult hospitalized patients and flags high-risk patients who can benefit from pharmacist intervention. Patient risk is scored based on a patient’s medical history, including medications and disease complexity, prior health care utilization, demographics and social determinants of health.

Help Outside the Hospital

“One of most important things for hospitals and clinics is to understand that it’s necessary to meet the patients where they are in their communities,” said Dr. Spielberg. She’s helping to train the next generation of physicians in understanding social determinants of health.

She teaches a course in community-oriented quality improvement. Candidates for a master’s degree in public health work with Dr. Spielberg while doing fieldwork with community partners to understand a community’s health needs. They then develop, implement and evaluate an intervention.

“Part of the solution is bringing care to the housing project. That’s important because health literacy is low in this population, and people don’t know what preventive and chronic disease care they need.”


One such intervention is Bringing Health Home, a partnership between Dell Medical School and the Housing Authority of Austin in which more than 200 low-income families living in a housing project in east Austin receive necessary health care, such as on-site tests and medications. By going door to door to assess residents’ health and socioeconomic needs, Dr. Spielberg found more than 75% of residents had at least one chronic condition, and many didn’t have access to preventive care through a primary care physician. And close to half of the residents had been in the emergency department in the past year.

“To have an impact on community health, we have to get out of the clinics. Part of the solution is bringing care to the housing project. That’s important because health literacy is low in this population, and people don’t know what preventive and chronic disease care they need,” she said.

Dr. Spielberg and one of her students are designing group-based visits as part of the Bringing Health Home program. They hope to improve patients’ heath literacy and will evaluate the impact of community health workers, who collaborate with residents to create individualized wellness plans that target their preventive and chronic illness needs while identifying social determinants of health that could deter them from getting healthier. By studying the impact of those wellness plans, Dr. Spielberg learns what interventions are working and how social barriers, such as lack of transportation or food insecurity, may be getting in the way of better health outcomes.

Tackling Children’s Social Determinants of Health

Texas Children’s Hospital is employing a variety of strategies to improve the health of the communities and families the system serves. Through the Community Health Needs Assessment, Texas Children’s regularly examines the community’s needs and develops a plan to address them. The Texas Children’s Section of Public Health has led pilot programs that aim to reduce maternal opioid use, postpartum depression and the impact of parental incarceration on children. These programs also work to integrate behavioral health and an understanding of Social determinants of health and adverse childhood experiences in a pediatric office.

photo of a child receiving medical attention, a teddy bear looks on

The hospital tackles a wide range of problems by underwriting and creating dedicated programs, including:

  • The Vannie Cook Children’s Clinic in McAllen, which offers advanced treatments and diagnostics from Texas Children’s/Baylor College of Medicine physicians in a comprehensive pediatric cancer and hematology center.
  • Texas Children’s Mobile Clinic Program, which provides free medical services to low-income, largely Hispanic neighborhoods to provide comprehensive health care to underserved children from newborn to 18 years old.
  • Texas Children’s Trauma and Grief Center’s Harvey Resiliency and Recovery Program, which serves the needs of the children and families adversely affected by Hurricane Harvey. The center evaluates traumatized and/or bereaved children ages 7 to 17 and provides ongoing evidence-based treatments.

Experts at Texas Children’s Hospital have found growing evidence to support the importance of a child’s social situation in determining the child’s long-term health outcomes. They are developing new ways to continue focusing on the social determinants of health children in their community face so that they can continue to improve long-term health outcomes.

Texas hospitals continue to work to standardize a system for identifying and addressing patients’ socioeconomic needs and the Social determinants of health that may prevent them from accessing much-needed care. For now, hospitals are focused on developing standardized screening tools that would allow hospital staff to connect patients with appropriate community resources, leading them down the path to better health.