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Evaluating a Population Health Approach to Addressing Social Determinants in the Community

Statement of Problem

Social determinants of health (SDOH), such as food insecurity and unstable housing, can lead to disparities in health outcomes, preventable use of health care services and increased health care costs. A growing body of research, including some of our own here at PolicyLab, suggests that screening to address SDOH within health care settings is a feasible endeavor and can lead to increased overall quality of care. There’s also emerging research that if health systems and community organizations work together to implement interventions, it can lead to fewer emergency department visits and improved health outcomes.   

Despite evidence suggesting that social needs critically impact patients’ capacity to manage their and their child’s health conditions, very few large-scale, collaborative interventions exist that utilize the health care system to connect families to community support services. For those interventions that do exist, we lack evaluations that can help us understand their true impact and inform improvements so all patients can receive care to meet their basic living needs.


Next Steps

Throughout our evaluation, we developed recommendations for improving the effectiveness of screening for SDOH and connecting patients to community support services through Intermountain Healthcare’s intervention. We continue to work to disseminate our research findings and recommendations for policy approaches to strategically targeted audiences who can support efforts to integrate SDOH interventions into clinical practice and finance them with existing state and federal programs.

Ultimately, through this evaluation and partnership, we hope to identify how health care systems can best connect patients to community services that address their social needs. In doing so, our goal is to generate first-of-its-kind knowledge about this kind of large-scale health system intervention in order to create sustainable mechanisms to improve the health outcomes of children and adults by addressing SDOH.

This project page was last updated in July 2023.

Suggested Citation

Children's Hospital of Philadelphia, PolicyLab. Evaluating a Population Health Approach to Addressing Social Determinants in the Community [online]. Available at: [Accessed: plug in date accessed here].