Programs

Social Determinants of Health & Health Equity

Social Determinants of Health Program

Social determinants of health (SDOH) are significant drivers of health outcomes. We recognize the importance of addressing the psychosocial needs of individuals in addition to their medical needs. SI PPS provides funding to community-based organizations to expand their capacity to serve individuals with SDOH needs. Utilizing a referral management platform funded by SI PPS, agencies assess individuals in the community for social need and make closed-loop referrals to social services and supports.

Each organization deploys care navigators and other staff to conduct in-person or telephonic outreach. Care navigators utilize customized workflows in the platform to collect demographic information, complete a standardized, proprietary SDOH assessment, identify SDOH needs, and make appropriate closed-loop referrals from a directory of community agencies. Each organization can monitor outgoing referrals, report on referral outcomes, and document ongoing follow-up with each individual.

Below is a breakdown of the 16,134 SDOH factors identified from the 9,501 surveys completed.