Examining the Integration of Hospitals, Public Health, and Social Services to Target the Social Determinants of Health Using Patient-Centered and Comparative Effectiveness Research Methods

Addressing the health-related social determinants of health has emerged as a leading strategy to combat the increasing economic and financial burden of preventable hospitalizations and readmissions. While it is important for clinicians to identify the health-related social determinants that may play a role in their patient’s hospitalization or readmission, those organizations that are best equipped to address social and environmental needs typically fall outside of the health care sector. As a result, national efforts that call for the integration of health care, public health, and social services systems have emerged. Most research to-date focuses on single organizations providing clinical care and not the cross-sector collaboration with other public and private organizations, in particular social services and local public health agencies, which might be occurring in communities around the social determinants of health. Those studies that have examined determinants tend to focus on broad socioeconomic factors like income and education and how they impact health outcomes, but still do not address the ways organizations work together to connect patients with the most appropriate services. The failure to factor in community models that target the social determinants may account for the recent controversy surrounding findings that indicate socioeconomic status does not impact readmissions. This study will use a mixed methods approach to examine in greater detail the models being used across the US to integrate public health and social services with clinical care provided in hospitals as a mechanism to target the social, behavioral, and environmental factors that contribute to hospitalizations and readmissions.