Patients walking out of a clinician’s office or a hospital typically leave with discharge instructions, medications and advice to remain healthy and prevent and control chronic conditions. But what happens after people leave the clinical setting? Their home and community environment may have greater influence on their maintaining good health than anything else.

Hospitals and health systems are investing in health-related social needs. They are taking the lead to address the social determinants of health, such as access to healthful food, adequate housing, transportation options and high-quality education. Addressing these nonmedical needs can have a profound, positive impact on health, including longer life expectancy. And the economic benefits for hospitals can be significant. For example, homeless or unstably housed individuals are more likely to be hospitalized frequently, have longer lengths of stay in the hospital, be readmitted within 30 days and use more high-cost services than are patients with stable housing situations. The health care system movement toward value-based care may lead to greater investment and action around social determinants of health. The challenge is sustainable funding and consistent community-based organizational partnerships given the uncertainty of funding, leadership and support.

The American Hospital Association's Health Research & Educational Trust is releasing a series of guides that provide strategies, tools and case examples to help hospitals and health systems address the social determinants of health. For example, to improve housing stability, hospitals are forming partnerships to support neighborhood revitalization; offering home safety assessments; providing medical care for the homeless; and building transitional or permanent supportive housing units for patients in need, among other initiatives. To reduce food insecurity, which is prevalent in low-income communities, hospitals are including screening in electronic health records; distributing food via on-site food pharmacies and mobile food pantries; and advocating to inform public policy on the health effects of food insecurity. 

Suggested key steps in developing programs and upstream interventions to address patients’ social needs include:

  1. Identify issues, opportunities and risks. Use community health needs assessments, patient demographics and health trends, and observations by staff to get valuable information.
  2. Build partnerships inside and outside of the hospital. Partners may include other health care providers, government agencies, social service organizations, schools and universities, and other community stakeholders.
  3. Research possible interventions and build on what worked before.
  4. Consider funding implications. Developing a funding plan is especially important, since return on investment may not be immediate.
  5. Educate and collaborate with patients, providers and the community. Community and provider buy-in is key to success.
  6. Measure improvement and make adjustments once data have been collected and analyzed.

Traditional payment models have reimbursed providers for medical interventions only, but that is changing. There are also unique partners that can be involved in a plan to address a social determinant. Clinicians and health care delivery now can offer comprehensive care that includes social supports to qualify as a medical home. And holistic patient care improves provider and patient satisfaction, which can increase reimbursement for care, improve employee retention and build and maintain patient loyalty.                                                 

As a health care leader, you are well-positioned to make an impact. Your hospital team understands the community you serve and likely already has ties with other health care and social organizations. By using data to identify community health needs and opportunities, building partnerships, considering funding issues, and evaluating and adapting interventions, hospitals and health systems can take the lead in addressing patients’ social needs and improving their health and overall community health.

For more information and to download the HRET guides, visit

Jay Bhatt, D.O., is president of the Health Research & Educational Trust and chief medical officer of the American Hospital Association.