IMI Blog


Addressing SDOH in Medicaid: Cross-Sector Collaborations to Support Initiatives

Noelle Serino

January 14, 2021


The social determinants of health are a priority for organizations across the health, business, and nonprofit sectors. Healthy People 2030, powered by the U.S Department of Health and Human Services and the Office of Disease Prevention and Health Promotion, divides the social determinants of health into five categories: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context. A 2018 report found that 68% of Americans struggled with at least one of these determinants and 52% faced moderate to high risk of at least one of these determinants.

Among the organizations leading initiatives relating to the social determinants of health are CareSource – a nonprofit managed care plan – and Healthify – a company that builds technological infrastructure to coordinate social determinants of health initiatives between community-based organizations and healthcare systems. CareSource established the partnership to construct a network of community-based organizations throughout Ohio. This network will provide referrals to social services to address food insecurity, lack of transportation, unemployment, inadequate housing, and financial instability to CareSource members. The partnership will allow CareSource to leverage their resources to identify social risk factors throughout the state, identify populations that face barriers to health, and connect them to the requisite care. It is their hope that the partnership will allow for meaningful improvement in member engagement as well as the ability to track the short and long-term social and clinical progress of members. Using this information, CareSource can then facilitate targeted outreach through specialized interventions.

CareSource’s collaboration is not their first venture into addressing the social determinants of health. Healthy Beginnings at Home is an infant mortality and housing pilot, provides rental subsidies and housing services to Medicaid eligible pregnant people that are or at risk of homeless and infant mortality in partnership with CelebrateOne, Homeless Families Foundation, Columbus Metropolitan Housing Authority, Nationwide Children’s Hospital. Launched in January 2020, the Post-Discharge Care program operated by Mom’s Meals provides two meals per day for two weeks after an inpatient admission stay in the hospital. The program was cited to have reduced readmission rates by 33% after 30 days and 23% after 90 days. To address education and job training, CareSource launched JobConnect™, a workforce development program that provides employment, education, and social determinants of health coaching. More than 17,000 CareSource members have interacted with the service with 1,849 members receiving employment from 582 employer partners, resulting in an employment retainment rate of 85%. CareSource’s deep commitment to supporting their members and addressing social barriers to care have produced tangible results improving not only health outcomes but quality of life as well.

As noted in IMI’s report Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care, Medicaid provides health care coverage to more than 70 million Americans that suffer from the effects of unmet social needs. In order to help identify and overcome these barriers to health and meet the social needs of the Medicaid population, IMI has established the social determinants of health subcommittee. The committee is dedicated to identifying and prioritizing issues relating to the social determinants of health and using these issues to create and build partnerships, identify projects and initiatives that address the specified issues, and purport funding opportunities to help realize such projects.

IMI has also established the social determinants of health as an emerging Medicaid topic and in doing so has published a multitude of reports and fact sheets on the topic:

● Fact sheet: Social Determinants of Health in State Medicaid Enrollment Forms Summary
● Report: Social Needs Data in the State Medicaid Enrollment Form: A Content Analysis
● Report: Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care
● Fact sheet: Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care Summary

A commitment to further address and research the social determinants of health will allow Medicaid programs to effectively address the needs of the populations that they serve. The collaborative efforts of CareSource underscore the importance of addressing the social determinants of health through cross-sector partnerships by identifying evidence-based strategies and potential paths forward motivated by achieving positive health outcomes for all.