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Hackensack Meridian Health's community health project

Courtesy: Virtua Health

Only recently have healthcare providers, insurers, government agencies and other stakeholders begun to recognize the impact that social determinants can have on health and well-being. Access to healthy food, stable housing, employment and education – not to mention social interaction – have all been undervalued in relation to their impact on health status. Clinicians should seek to factor these variables into patient evaluations. Doing so will allow for a broader and more comprehensive approach to care delivery.

Investments in social determinants intervention programs can have the real impact of bending the healthcare cost curve. This study has demonstrated a linkage across New Jersey between unfavorable social factors and poor health status/increased health vulnerability. Ignoring this linkage will only serve to forestall society’s ability to broadly improve health status in the most vulnerable communities. If healthcare services are brought to the community, residents are more likely to take advantage of needed services. Examples of outreach programs include mobile asthma vans, mobile outreach vehicles, community-based care and tutoring vans for underprivileged communities.

While this study has identified New Jersey’s most vulnerable communities, it also can serve as a road map of where strategic investments can lead to significant improvements. An emerging community development sector seeks “to improve the social, physical, and economic conditions in disadvantaged neighborhoods through developing and financing affordable housing, schools, grocery stores, community services such as child care and health clinics, economic and workforce development projects, and other activities that revitalize or stabilize low to moderate income areas.”10 Expansion of community health worker models focused on mental health, chronic condition management and first aid options should be explored. Using clinical data with social determinants together provides the ability for clinicians and policymakers to make proactive decisions that will improve population health.

Solutions will not be grounded in a one-size-fits-all approach. They must be customized to the needs of each community. CHART’s zip code-level vulnerable community analysis illuminates that inroads must be made one zip code at a time.