Enhancing Partnerships to Address Social Determinants of Health (SDoH)
ABOUT THIS PLAYBOOK
The Social Determinants of Health (SDoH) are the basic building blocks of health and play a substantial role in determining negative or positive health outcomes. Integrating SDoH health behaviors, physical environment, and social and economic factors into one’s plan of
care go a long way in determining positive health outcomes. Healthcare providers embrace the importance and the impact SDoH have on one’s health and realize management of SDoH must be done across the continuum. Focusing our efforts on building a connection to community resources accelerates the paradigm shift to person-centered care and improving their total health.
The Illinois Health and Hospital Association (IHA) has partnered with Coordinated Care Alliance (CCA) on an initiative that brings together healthcare facilities and local community-based organizations in an effort to enhance their collaboration. This partnership has moved the needle when it comes to addressing SDoH in the community and thus meeting whole-person needs of the individuals they serve. IHA and CCA have worked with cohorts of healthcare facilities and CBOs to increase knowledge about the underutilized services that CBOs provide, identify patient needs in the community, discuss referral processes, review feedback systems, and evaluate data exchange to improve transitions of care for individuals.
The aim of this work is to strengthen the collaboration and handoff between healthcare entities and CBOs to ensure individuals receive the support they need in the community. For example, past cohorts have increased collaboration to address nutrition and caregiver
support needs. This playbook will walk your organization through the steps to enrich the relationship, identify and address gaps in care as it relates to the SDoH and improvereferral processes.
The Cast of Characters
The storyline behind the Playbook involves these wonderful people, places and organizations
Illinois Health and Hospital Association
Through the Hospital Improvement Innovation Network (HIIN), IHA worked with the Westside ConnectED coalition to support SDoH screening in hospitals, and create the implementation playbook that will be used to spread the successes of this work to other communities.
Coordinated Care Alliance
Coordinated Care Alliance is a statewide network of
Care Coordination Units (CCUs) in Illinois. CCUs link
the right community resources to support older adults and individuals with disabilities to live safely in their homes.
Healthcare facilities play a significant role in providing comprehensive care to patients. By addressing social determinants of health (SDoHs), healthcare facilities can reduce readmissions and improve the health of individuals in the community.
Community Based Organization
Care Coordination Units (CCUs) are community
based organizations (CBOs) that provide services
and supports to ensure older adults and individuals with disabilities receive the care they need in their homes.