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Social Determinants of Health

We know people don’t live in hospitals, they live in communities. As they say, if you know one city or small town, you know one city or small town. No two geographies are the same, and researchers have shown that your zip code can have more impact on your health than your genetic code.

Table of Contents

What are the social determinants of health and what do they mean for community health?

Efforts to improve health outcomes in the US have traditionally prioritized healthcare delivered within the walls of clinical settings. There has been increasing recognition over the past decade, however, that certain social determinants greatly impact an individual’s health. These are the conditions in which people are born, grow, live, work, and play. Due to the increased recognition of the role social determinants play in health outcomes, we’ve seen a movement within the healthcare system to address these social determinants to improve health outcomes while driving down costs.

Social Determinants of Health (SDoH)

Addressing SDoH

Listen to more of Dan’s feature on the Beyond the Molecule podcast below.

At Unite Us,

we connect health and social care, elevating social care to the same level as healthcare. While “social determinants of health” may be the terminology that carries the day, our solution builds on work that has been taking place in communities for decades. Social care and the community-based organizations (CBOs) that provide these critical services have long understood this connection to an individual’s health and well-being. Yet this sector has been underfunded, left to survive on philanthropic funding with little to no technological advancement, research or data, or accountability.

The future of health is in the community

We know people don’t live in hospitals, they live in communities. As they say, if you know one city or small town, you know one city or small town. No two geographies are the same, and researchers have shown that your zip code can have more impact on your health than your genetic code. At Unite Us, we partner with each of our networks to drive toward a model of value-based social care – a unified system connecting individuals to quality services, tracking outcomes delivered across an accountable network, and ensuring equity so all communities can thrive.

Accelerated movement

Before modern medicine, public health practice addressed the root causes of health through community monitoring and engagement practices. With the emergence of antibiotics and modern medicine in the 18th century, public health approaches to prevention became underfunded and under-prioritized, turning US healthcare into a reactive, clinically focused system rather than one based on keeping people healthy in the first place.

During the past decade, however, the reality that community conditions and social needs largely influence health outcomes has become mainstream. Further, the widespread understanding of the impact of social needs and community factors on clinical outcomes has collided with our nation’s lack of preparedness for the COVID-19 pandemic. Never in modern times has the importance of developing community-based solutions to address SDoH been more crystallized, as COVID outcomes further highlight the stark inequities in health that are tied to community and social needs.

Black COVID-19 Death Rates

In the 16 states where black residents' share of the population is higher than the national percentage, the prevalence of death among black residents exceeded their population share by as much as 25%.

Coupled with the social needs fall-out from the worst economic downturn since the Great Depression, local and state governments, as well as the Federal Government, are expediting efforts to address the desperate social needs of Americans while working Medicaid1 and Medicare Advantage2 payment models, public/private partnerships3, and philanthropy investments4 aimed at addressing social needs. Together, these mechanisms to invest in the foundations of health are beginning to fill the chasm created by a historical lack of spending on social services and public health. While these models are promising, widespread investment and adoption across entire states and on a national level are the only pathway to sustainable systems transformation.

Buying Health, Not Healthcare

The shift within healthcare to value-based care validates the role and impact of community providers on health outcomes. Through our work across the country, we are seeing firsthand the positive change that is happening in communities through cross-sector coordination and partnerships that elevate social care to the same level as healthcare.

Impact on health outcomes and spending

Consequences associated with unaddressed social determinants of health5

Outcomes and Impact

In order to drive widespread impact through investments in social care, the ability to track, measure, and analyze social care data and outcomes is critical. As investments move further upstream communities must adopt a standard for social care data to better inform policy, programs, and innovations across the country. Calculating the ROI on addressing social needs is complex, since needs are often co-occurring, persistent, vary across individuals, and require rich datasets that include information on whether or not needs were met. Despite these challenges, efforts to quantify ROI on addressing the social determinants of health are cropping up around the country and starting to show promising results. In an effort to add structure to social care ROI calculations, The Commonwealth Fund recently published an instructional playbook on how nonprofits can calculate a healthcare ROI for their services in order to facilitate payments for delivering social care.

Unite Us has worked with partners to complete several evaluations of the impact of its networks. As the only national coordinated SDoH network, we have the ability to collect data on social needs, including whether or not a person’s needs were met through referrals in our network, and to analyze our data to understand the effects of addressing social needs on health outcomes. Our standardized outcome data provides our partners with actionable insights that can be used to improve resource allocation, to improve quality of care and to reduce costs.

The SDoH system we are building with Unite Us will enable the improvement of population-level health outcomes.

– Jamie Bland, President and CEO of the Nebraska Health Information Initiative (NEHII)

Despite growing evidence about the importance of addressing social needs to improve health outcomes, there are many research questions that remain. Numerous studies show the effects that community level factors and resources have on health outcomes, and many other studies show the impact of an individual’s social needs on outcomes. A few studies have even looked at changes in outcomes based on whether or not individuals were referred for a need, however to date, no studies have been able to look at the whole social care journey - from community level risk factors, to individual level social need identification, to referral to a CBO, to whether or not that need was successfully met- in a meaningful way. The data Unite Us captures allows partners to understand that whole social care journey in a way that can begin to answer outstanding questions on the return on investment and return on value created by screening, referring, and addressing social needs.

Our approach to building healthier communities

Coordinated Care Networks

“The qualities that I think Unite Us’s staff brings to the table is a genuine desire to see people’s lives improve, this isn’t a bunch of IT people walking in with a platform and saying ‘here you go, plug and play.’ It’s people who are really engaged in the idea of helping people live the best life they can and the healthiest life they can.”

— Erin Booker, LPC, Vice President, Community Health and Engagement, ChristianaCare
"These are the places that I grocery shop, these are the places that I live and work in, it's where my family and I walk, it’s all the social determinants of health and that’s my environment. When I think about Unite Washington, Unite Us, and the role I do, I don’t think about it short-term. I think about it as this very long-term vision because to connect to a community, you can’t do it in a short stint. These relationships take time to grow, to flourish, to cultivate.”

– Gracious Gamaio, Community Engagement Manager, Unite Us
"When helping people on their path to better health, we value innovation and collaboration. Unite Louisiana brings together community-focused companies to help Louisianans get access to the resources and support they need."

– Richard Born, CEO, Aetna Better Health of Louisiana, a CVS Health company

Building and maintaining coordinated care networks can be challenging. That’s why our team of public health professionals live and work in the communities we support. Our work doesn’t end after we launch a network. Hiring locally allows us our networks to be built and optimized by the very people solving problems at home while they continue to work and invest in that same community.

As industry leaders such as Kaiser Permanente and the state of North Carolina boldly move to change care delivery for good, they’ve partnered with Unite Us to provide infrastructure and resources to build coordinated care networks embedded in communities throughout the entire country. We have the resources, people, and processes to build networks from the ground up – repeatedly and at scale.


Despite good intentions to improve care and lower costs, no one has developed a systematic, comprehensive solution that connects health and human service providers in a person-centric model — until now. Unite Us’ intuitive and seamless technology, coupled with our experts working within communities, is changing the traditional care delivery model to one that holds providers accountable and goes beyond the referral.

Until recently, no one measured social care outcomes in a cohesive, precise way. We’ve established a standard for providers across the continuum of care to understand the impact of meeting people’s social needs. With our accurate and structured outcome data, our partners can make informed decisions and take action to effect change and address gaps in services. This is a crucial step towards value-based contracting for social services.

For health and social care entities who want sustainable systems that focus on both the social and clinical determinants of health, Unite Us Payments offers pioneering technologies and services to open new payment streams and promote whole person care that augment and refine relationships between buyers of health and social service providers

Unlike the current marketplace, which has no meaningful way to use healthcare dollars to invest in addressing social needs, our products challenge the current paradigm of reactive, clinically-focused systems of care, instead promoting payment solutions for investment in the foundations of whole person care.

Learn more about SDoH

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