Social determinants of health case studies for students

What can community health centers do to address the upstream factors that impact their patient’s health? A lot! 

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Generally speaking, CHC activities dealing with social determinants fall into three categories:

• Provide enabling services to directly address the non-clinical barriers that patients face.
• Partner with community and social service organizations that work on upstream factors.
• Engage in advocacy and coalitions to change the systems that negatively impact their patients.

Among the concerns regularly identified by CHC patients, food and housing regularly top the list.  More than 95 percent of CHC patients in Oregon live at or below 200 percent of the federal poverty level, and many face difficult choices on where to spend their limited resources. Patients may have to choose between paying for groceries and paying for medications, a tradeoff that is particularly devastating for patients with one or more diet-related conditions like diabetes or hypertension. Other patients juggle medical bills, rent and utilities.

Check these examples of how CHCs address SDH issues.

Food Insecurity Case Studies

Nutrition was a major focus of the original health center movement of the mid-1960s.  Today, health centers continue to work with their patients to address food needs. CHCs connect patients to additional food resources, tailored education and nutrition programming.  Some examples:

• A pilot at the Multnomah County Health Department CHC encourages doctors to write prescriptions for healthy food.

• To connect patients with additional food sources, health centers often partner with community partners like food pantries or food banks. Some even host a food pantry and encourage supporters to "adopt an item" for the pantry.  Other clinics provide a farmers market or community garden onsite. Still others enroll patients in WIC or SNAP and help patients navigate the application and renewal process.

• Health centers educate government institutions about the need for positive change. For example, Hudson River HealthCare took the lead in working with the local Migrant Head Start program to improve nutrition. They also collaborated with the New York State Migrant Program Parent Advisory Committee to successfully change the milk offered at Migrant Head Start centers across the state.

• Food insecure patients are more likely to have chronic conditions and experience greater challenges in managing them. For more thoughts on ways that health systems can address food insecurity, especially for patients with chronic conditions, check this presentation by Feeding America. 

Housing Insecurity Case Studies

Health centers tend to focus on three types of housing concerns: homelessness, housing insecurity, and housing quality and safety. Check these examples for ideas on how your health center could address one or more of these concerns:

• Boston Medical Center’s Medical-Legal Partnership paired physicians and attorneys to protect patients whose utilities had been shut off in winter. The clinic began screening patients, added a form letter to the EHR and hosted a legal clinic on-site. They successfully advocated for regulatory changes so that fewer people face shutoffs and other licensed staff could document medical need.

• Several health centers included in a set of Institute for Alternative Futures’ case studies address their patient’s housing needs. Some provide housing units for targeted populations (low-income, farmworker families, transitional housing for people in recovery or homeless families). Others conduct home visits for fall prevention and safety, help patients navigate the housing market, and provide financial literacy classes on banking, loans and building credit. Several originate or participate in community conversations around improved and affordable housing.

• Pilot programs around the country - including one in Portland - have shown promising cost savings and improved health outcomes by addressing the housing needs of high utilizers of the health care system. These patients often experience chronic homelessness or unstable housing.  Learn more in this report from The Commonwealth Fund and a case study of Portland's pilot from the U.S. Department of Housing & Urban Development.

Community Partnership Case Studies

• The Institute for Alternative Futures has compiled a database of CHCs who address the social determinants and also highlights 10 in-depth case studies.

• The Robert Wood Johnson Foundation Culture of Health Prizes are granted to communities who bring multiple sectors together to improve health outcomes.

• The Public Health Practical Playbook supports primary care-public health partnerships and includes a series of case studies to jumpstart your thinking.

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