Promising Practices

An increased level of health for all Americans is key to the promotion of thriving lives, economies, and communities. Current reform efforts to lower costs and promote value in the health care system are rewarding value over volume and emphasizing prevention and care coordination in the optimal balance with treatment. However, improving health will require more than even the best performing medical system because disease rates and costs cannot change by acting solely within the walls of hospitals and clinics.

Addressing non-medical health drivers will require innovative, comprehensive solutions from the public and private sector. Today, the private and public health care markets are embracing the opportunity to improve health by piloting new value-based payment and delivery models, digital and data platforms, and community improvement strategies that address and incorporate upstream indicators of health.

The information below is intended to inform interested parties of these existing resources and best practices that can be leveraged to address the social determinants of health. The resources included on this page are not an exhaustive nor endorsed list. We have initially drawn heavily on work our members are directly familiar with, but this is intended to be illustrative of a broad and evolving body of work in the community rather than exhaustive accounting of work in the field. Please visit the site over time as we continue to update as the field evolves.


The BUILD Health Challenge – Healthy Homes Des Moines

The BUILD Health Challenge focuses on multisector, community-driven partnerships to reduce health disparities caused by social inequity. The Healthy Homes Des Moines (HHDSM) initiative worked on reducing pediatric asthma-related hospital visits through improving social, economic, and environmental factors with the greatest impact on asthma. The goal of the initiative was to improve housing, health education, and indoor air quality, while promoting self-care and lifestyle changes. The approach included a four-step process beginning with referrals by examining patient and housing data. Referrals were made by hospitals, emergency rooms, clinics, and school nurses’ offices. Next, a home inspector identified asthma triggers in each child’s home which was followed by contractors making home repairs. Finally, community health workers conducted education programs for participants on how to control asthma symptoms.

HHDSM experienced a handful of successes including the development of a robust, integrated partnership between fifteen partners including the Polk County Housing Trust Fund, three competing nonprofit hospitals, the local health department and school district, and several community organizations and a comprehensive, online data system providing health care providers a method of referring patients. One key of HHDSM’s success was the ability to integrate data throughout the program. The overall referral process was critical and allowed physicians and hospitals to make direct referrals and track patients’ clinical and nonclinical services received through the home intervention, as well as allowing access to data for all partners. Overall, shared data was used to unify all partners involved, to inform and develop the initiative activities, and to measure project impact on return on investment (ROI). The initiative provided 62 families in-home asthma education, 42 homes were repaired including $150,000 worth of repairs, 38 families completed all intervention steps, $17,000 in supplies were given to families, and 6.2 more asthma-free days per month for children was achieved.

Michigan Health Improvement Alliance (MiHIA)

The Michigan Health Improvement Alliance (MiHIA) is a multi-stakeholder, community collaboration with the aim to take action and drive system change that effectively advances health for a 14-county region. MiHIA utilizes a proven combination of elements called “The Quadruple Aim”: better care experiences, better health, affordable care while improving the work life of health care providers. MiHIA recognizes that the overall success of communities or regions cannot be separated from a clear strategy with focus on the interdependence of health and the economy. Achieving health advancement requires attention to its determinants and critical system aspects including structural and cultural living conditions supporting health, fluid health care delivery for everyone, effective use of technology, innovation, and appropriate industry sector growth. Recently, MiHIA has successfully partnered with the Great Lakes Bay Regional Alliance (GLBRA) creating a join initiative, THRIVE. THRIVE’s vision is significant improved health and sustained economic growth in the 14-county region.

MiHIA’s foundation of more than a decade of regional collaborative efforts position it for the current initiative targeting both health and the economy. With partners across the health ecosystem, MiHIA selects intervention levers that make meaningful changes.  For example, MiHIA’s Regional Diabetes Prevention Program (DPP) has achieved the goal of preventing or delaying the onset of Type 2 Diabetes while providing very significant health care cost savings. The program model utilizes broad screening to identify and enroll eligible individuals and facilitate reducing risk factors of diabetes. In developing the regional programming, utilizing the CDC recommended model, MiHIA engaged federal agencies, community-based organizations, employers, insurers, health care professionals, academia, and other stakeholders for the support of this program. With MiHIA committed to sustainable system level change, the DPP initiative required broadly transforming the health ecosystem to create new norms which included: achieving an understanding and urgency of the provider community; utilizing new referral and scheduling systems, and convincing payers to make DPP benefits reimbursable. In just two years after implementation, the program enrolled 483 individuals, resulted in over $1.1 million in current health care savings, with a predicted $3.2 million in health plan savings annually going forward. Additionally, over 128,000 individuals were enrolled in a health insurance plan that added DPP as a covered benefit.

Center for Disease Control and Prevention’s (CDC) 6/18 Initiative

The Center for Disease Control and Prevention (CDC), through partnerships with health care purchasers, payers, and providers, are aiming to improve health and control costs using the 6/18 initiative. The initiative targets six common and high-cost health conditions (e.g. tobacco use, high blood pressure, health care-associated infections, asthma, unintended pregnancies, and diabetes) using 18 proven interventions. CDC partners with 15 state Medicaid programs and their respective state public health departments to implement and improve the 6/18 interventions in their populations served. States responded on their experience and how it has positively impacted their states.

One such state, South Carolina, worked on enhancing tobacco cessation benefits in their Medicaid program. They worked to include several payer interventions suggested by the 6/18 initiative, including:

  • Expanding access to evidence-based tobacco cessation treatments, including individual, group and telephone counseling and FDA-approved cessation medications.
  • Removing barriers that impede access to covered cessation treatments, such as cost-sharing and prior authorization.
  • Promoting the increased use of covered treatment benefits by tobacco users.

South Carolina’s Medicaid agency partnered with DHEC, the state’s public health agency, who assisted in the 6/18 initiative through leveraging surveillance data and reinforcing South Carolina’s tobacco quitline for free counseling with skilled behavioral health coaches. Beginning July 1, 2017, SCHDDS made treatment options available for all full-benefit Medicaid members including all seven FDA-approved medications with no prior authorizations, co-pays, and included medically appropriate combination therapies.

Episcopal Health Foundation: Texas Community Centered Health Homes Initiative

Episcopal Health Foundation’s Texas Community Centered Health Homes (CCHH) Initiative is a four-year, $10 million investment to create more active roles for clinics to address the community conditions that lead to poor health. The initiative creates a model for 13 community-based clinics to go beyond the exam room with a systematic approach to address the non-medical factors that contribute to poor health. Clinics are developing specific ways to take community-wide action to prevent illness and improve health, not just healthcare in the areas they serve.

Poverty, substandard housing, lack of affordable healthy food, and limited safe places to exercise are a few of the underlying conditions that contribute to high rates of chronic health issues like obesity, diabetes, heart disease, asthma, and more. As described by Prevention Institute, a CCHH clinic “not only acknowledges that community conditions outside the clinic walls affect patient outcomes, it actively participates in improving them.” The CCHH approach goes beyond patient-only treatments and promotes change at the systems and community levels. Clinics are partnering with community groups, government agencies, schools, businesses, and other organizations to create community-wide prevention strategies and other similar efforts.


General Electric – HealthyCities Program

Since 2010, GE has been building coalitions across the public and private sectors to develop community-based programs that improve health, lower healthcare costs, and make a real economic impact in the communities where GE employees and their families live and work. GE believes these efforts — investing in initiatives to connect healthcare, public health, and community efforts like education, housing and public safety — will improve health and social needs in a sustainable and scalable way. There also exists critical commercial value and new business models around improving social needs and addressing the larger social determinants of health.

The GE HealthyCities Program has continued to show improved health and well-being in communities throughout the US:

  • In Cincinnati, an evaluation of our program showed a reduction in hospital admissions, reduction in ER visits, and reduction in childhood asthma rates 24 months after implementation leading to improved health outcomes for Cincinnati and reduced healthcare costs for GE.
  • In Erie, as a result of developing educational materials to enhance health literacy in the community, we created a pilot program to aid physicians serving immigrant populations to upgrade their EHR systems.
  • In Houston, we worked to create a key leadership group that coordinates overall initiatives addressing social determinants of health (like a program for prescriptions to food banks for food insecurity). As a result of this work, the Houston Food Bank has been able to site their food distribution centers in areas of highest need.
  • In Boston, GE and the Network for Excellence in Health Innovation is working on a new initiative that draws in diverse partners including government, hospitals, universities, insurers and providers to integrate clinical data, claims, and the social determinants of health data to create actionable connections for better decision making.

In an effort to grow and test the scalability of GE HealthyCities work, a nationally focused pilot was created in 2016-2017 to teach leadership and cross-sector collaboration and capacity building. Harnessing open innovation, we recruited and resourced 9 diverse communities who worked to engage community-wide collaboration around a myriad of upstream social determinants of health topics.


Aetna and Mercy Care Plan

NORC at the University of Chicago developed this case study of supportive service expansion for individuals with serious mental illness enrolled in the Mercy Maricopa Integrated Care Medicaid managed care plan in Maricopa Counta, Arizona, through a series of structured interviews with stakeholders ranging from service providers to patient advocates. This case study provides background and historical information on Mercy Maricopa and the population it serves and examines the 1) policy drivers, 2) partnerships, and 3) organizational decisions and staffing alignment that have influenced Mercy Maricopa’s implementation of expanded support services, including employment and housing supports. The case study also explores the successes and challenges identified by stakeholders.

Policy Drivers

Several key policy and legal drivers played a significant role in the implementation and expansion of supportive services for the serious mental illness and general mental health and substance use disorder populations in Maricopa County, specifically the Regional Behavioral Health Authority transition and the Arnold v. Sarn court decision.


Building partnerships with government officials, providers, and stakeholders involved with the serious mental illness community has been an important part of Mercy Maricopa’s process when designing, implementing, and expanding its care model. These partnerships have enabled Mercy Maricopa to create a system of care that is responsive to and anticipates the needs of its members.

Organizational Decisions and Staffing Alignment

Mercy Maricopa has made several strategic network and staffing decisions that have played important roles in the implementation of Mercy Maricopa’s expanded housing and employment support services program for individuals with serious mental illness.

Lessons Learned

  • Establish a Member-Centered Framework: Mercy Maricopa takes a “member-centric” approach, focused on ensuring that members have maximized agency in obtaining and directing their services and supports.
  • Strengthen and Maintain Stakeholder Partnerships: Mercy Maricopa leadership was deliberate about incorporating itself into the local network of organizations working with individuals with serious mental illness, enabling it to unify its service delivery approach by ensuring that strong connections with providers led to consistent and best practices across clinics.
  • Nurture and Sustain Good Communication: Mercy Maricopa has worked closely with providers to help clearly communicate expectations, focus on improvement, and enhance relationships, promoting substantial growth and flexibility.
  • Be Strategic with Resources: Strong partnerships with robust communication also encouraged Mercy Maricopa to identify strategic uses for limited resources.

AmeriHealth Caritas: Innovative Uses of On-Demand Transportation Services

The Challenge:  AmeriHealth Caritas District of Columbia has long recognized that access to affordable, convenient and reliable transportation plays a crucial role in terms of member access to important preventive health services.  When it’s highly inconvenient to get to the doctor, members often put off care until situations become urgent, which often results in ambulance calls, emergency room (ER) visits and hospital stays. Like other Managed Care Organizations (MCOs), AmeriHealth’s traditional non-emergency medical transportation (NEMT) options for Medicaid recipients in the Washington D.C. area required three- to five-day notice. These trips also tended to be longer than needed, mostly because 1) members had to be picked up well in advance of their appointments and 2) drivers had to pick up and drop off multiple riders throughout the trip. Often times, this situation resulted in members having to give up a half-day of work or more just to go to the doctor.

The Solution:  In November of 2017, AmeriHealth set out to address this situation by forming a relationship with Lyft to provide on-demand transportation services to AmeriHealth Caritas DC members.  Today, as part of this relationship, AmeriHealth uses Lyft in two ways.  AmeriHealth members can call into the AmeriHealth Caritas DC Community Outreach Solutions Team which can book rides directly for members through the Lyft Concierge online portal. Rides booked through this channel are focused on transportation to and from plan sponsored health promotion programs, health education classes and related valued added services. And when members want to schedule rides for medical services, they call the non-emergency transportation (NEMT) toll-free number on the back of their membership card, which connects them to AmeriHealth’s transportation broker, Access2Care. Access2Care has significant experience in the NEMT space and it has extensive experience in working with Lyft, booking services through their customized Lyft portal.

The Results:  Preliminary analysis revealed a significant reduction inpatient stays, ER admissions, and emergency ambulance transportation utilization for those members taking Lyft trips during the initial launch of the Lyft program. These findings were based upon examining claims data six (6) months prior to a member’s first Lyft trip and claims data for that same member six (6) months after their first Lyft trip.  Furthermore the program has been correlated with a significant positive impact on the plan’s HEDIS results. The plan found that members using Lyft had higher compliance scores on thirty-two (32) of forty-two (42) or seventy-six percent (76%) of the measures and the members using Lyft had a statistically significant higher compliance score for nineteen (19) or forty-five percent (45%) of the measures.  And Lyft users had a ninety-five percent (95%) compliance rate on the Adults Access to Care measure as compared to sixty-nine percent (69%) of all other eligible members and a ninety-six percent (96%) compliance rate on the Children and Adolescents Access to Care measure as compared to eight-eight percent (88%) of all other eligible members.


RWJBarnabas Health

RWJBarnabas Health’s leadership is at the forefront of ensuring a movement from merely implementing basic community-level involvement and benefit projects to implementing policies, procedures, structures, and resources that drive positive social change as a core component to its system operations. The health system incorporates public policy efforts to encourage healthy communities and continuous evaluation to track and measure change. Through this method, leaders can plan and determine future opportunities for collaboration with many government and community stakeholders in order to achieve a more equitable future for all. RWJBarnabas Health has recently focused on food security initiatives including the Beth Greenhouse and Farmers Market and the Newark Food Security Project.

The Beth Greenhouse and Farmers Market

Healthy communities are food secure. People have opportunities to make healthier food choices if communities produce, rather than import, their own food and have more local food distribution centers (farm and retail).

  • The Greenhouse provides access to healthy, affordable produce to residents of the greater Newark area.
  • Newark Beth Israel Medical Center became the fi­rst New Jersey-based hospital to accept SNAP benefits.
  • The Farmers Market sells our own and locally-grown produce at affordable prices.
  • Newark Beth Greenhouse continues to provide educational programming, job training, internships and employment opportunities
  • Food is also donated to local soup kitchens and youth community organizations such as Greater Life, located in the South Ward of Newark.
  • 2,100 pounds of food were donated to local food banks by the Greenhouse.

Food for Thought Documentary

The Newark Food Security Project is an initiative aimed at identifying opportunities to enhance, and create greater access to, Newark’s healthy food supply. The project is a collaborative initiative being spearheaded by Newark Beth Israel Medical Center, the Greater Newark Community Advisory Board, and partner community-based organizations. Food for Thought: The Path to Food Security in Newark, NJ is a documentary that was created in 2017 by young adults (ages 12 to 21) from Newark area schools and community-based partner organizations.  23 youth were trained as citizen journalists to chronicle the spectrum of food resources and food availability in the city.

  • The documentary highlights community-based assets and ideas about solutions to addressing food insecurity. It features interviews with community activists, urban farmers, public health experts, city officials, and local youth ambassadors.
  • Long-term Outcome: Increase utilization of urban gardens, green house and farmers markets; develop generation of community advocates.
  • Currently: Screening the documentary throughout the city over the next few months. The goals of the community conversations are to:
  • Raise awareness about the importance of having access to high quality, affordable food.
  • Collect community wisdom and recommendations about what can be done to advance total food security in Newark.
  • Create an action plan to address food security issues.

Kaiser Permanente

Kaiser Permanente’s innovative framework – “total health” – uses and aligns all its resources to maximize physical, mental, and social wellbeing for its beneficiaries and the communities in which they live. These resources include sourcing and procurement, workforce pipeline development, training, investment capital, education programs, research, community health initiatives, environmental stewardship, and clinical prevention.

It emphasizes high-impact approaches like workforce wellness initiatives for employers and customers, increases access to healthy foods and physical activities in schools, and reduces Kaiser’s institutional carbon footprint through purchasing green energy. Kaiser also supports local economic development in communities of color through purchasing from women and minority-owned organizations. Kaiser Permanente actively pursues a “values- and mission-guided corporate strategy” in their effort to maximize and support the total health of their members and the communities they serve. The total health framework has three inter-related facets:

  1. Focus on the “whole person” – physical, mental, and spiritual wellbeing
  2. Commitment to deliver the best health care services through its delivery system, with health-promoting community assets integrations (e.g. healthy food, safe housing, transportation, support from community health workers)
  3. Gathering all of Kaiser Permanente’s assets to bear in support of the health of its members

Kaiser Permanente recognizes the importance of access to health-promoting environments (e.g. work, school, and diverse community settings where people spend much of their time) in addition to working on individual behavior changes. In order to address the social and non-medical needs, Kaiser Permanente also screens patients for unmet social needs and refers them to resources in their communities.

Intermountain Healthcare

Healthcare researchers have long known that social determinants are a major influence on healthcare outcomes and costs. The World Health Organization has described these nonclinical factors as “the conditions in which people are born, grow, live, work and age,” which in turn “are shaped by the distribution of money, power and resources at global, national, and local levels.”

In order to locate and refer patients to resources that address social needs, the healthcare system must have a standardized approach to screen for these conditions and document them. In August 2016, after surveying different tools available, SelectHealth elected to implement the PRAPARE one-question social determinant of health screening as a part of our overall strategy.

SelectHealth piloted the PRAPARE screening in our Care Management program as a part of the member’s initial and ongoing assessments for all lines of business. SelectHealth has analyzed this data to look for trends in unmet needs and build a partnership with United Way 2-1-1 Program to create more effective referrals to community resources. During this process, gaps in services were identified like urgent transportation for Medicaid members. This led to the creation of a pilot program where Care Managers can order a ride for Medicaid members who need urgent care but do not have access to transportation. Work to further expand PRAPARE screenings throughout the Intermountain Healthcare system in clinics, hospitals, and specialty services began in September 2017.



CHI St. Vincent Infirmary in Little Rock, Arkansas used TAVHealth’s cloud-based collaboration platform, TAVConnect, to address vulnerable patients who became reliant on the emergency department. Through their Health Connections Initiative (HCI) pilot program, TAVConnect was used to increase coordination, collaboration, and manage social determinants of health among participants. TAVHealth identified the most vulnerable members through hot spotted zip codes and integrated the highest ED utilizers and their demographics in the TAVConnect platform. Collaboration among health and community partners increased coordination for these patients’ post-acute care. Social workers performed home visits to identify each patient’s social determinants of health and assigned the social risk to the most appropriate community resource.

As a result of this initiative and partnership with TAVHealth, a 30 percent reduction was seen in 30-day hospital readmission rates, 35 percent reduction in inpatient rehab admission, a 17 percent reduction in cost per patient admission and a 10 percent reduction in the length of inpatient admissions. In addition, patients reported an increase in their confidence to manage their health, more meaningful relationship with their PCP, and reduced symptoms of depression.