How Can ACOs Help Address Social Determinants of Health?

Social Determinants of Health (SDOH) can have a large impact on the physical and mental health of patients. The Center for Disease Control and Prevention (CDC) defines social determinants of health as conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks and outcomes. Some of the most important social determinants of health that are dominant in the literature are education, housing and living environment, income and its distribution, stress, early life, social exclusion, work, unemployment, social support, addiction, food, transport. 

Estimates suggest that between 40 to 90 percent of health outcomes are attributable to social, behavioral, and economic factors.  Although these are high percentages, there is still a lot of work to be done to integrate social services with routine medical care to improve these outcomes. New payment models, such as accountable care organizations (ACOs), are becoming more popular as one potential way to help with this implementation. Under ACO models, participating health care providers are paid incentive bonuses when they meet quality performance targets and reduce overall costs of care.

The Health Affairs study reports that transportation, housing, and food insecurity are the three most common nonmedical needs that ACOs are addressing to improve health outcomes.

SDOH have been shown to impact health care utilization and cost, health disparities, and health outcomes. As social factors have a significant impact on health outcomes and medical costs, many providers working with ACO contracts can address the underlying social factors as one way to help control costs and improve quality. Although the use of ACOs has continued to rise, little is still known about how they are actually working on social service integration.


Transportation is a common barrier to patients receiving timely care. While ACOs in suburban or rural areas may experience more challenges, the Health Affairs study suggests that ACOs address the need for reliable transportation in the following ways;

  • Collaborating and working with transportation companies in the community to ensure reliable transportation for patients
  • Helping to provide public transportation passes to patients, either on a one-time basis or monthly basis if needed
  • Developing new technology and programs, such as mobile apps, to allow patients to request transportation in an easier and more user-friendly way
  • In suburban communities, ACOs investing in local community medical transportation agencies so they are able to expand services and provide more options for patients 
  • In rural communities, ACOs partnering with for-profit transportation agencies and negotiating a certain rate per member, per month, which allows patients access to 24-hour telephone service to arrange immediate transportation for unscheduled medical services

According to a report by the National Center on Family Homelessness, approximately 3.5 million people in the US experience homelessness every year.  ACOs have been working to address housing needs of patients through multiple different approaches. Some of the strategies that ACOs use to address housing needs are;

  • Developing partnerships with external housing agencies and working with public health and community agencies to provide housing to vulnerable patients
  • Developing new solutions, such as negotiating substance use requirements to allow patients to first receive housing before beginning treatment
  • Negotiating with housing agencies to designate beds for ACO patients not appropriately discharged from the hospital, which helps to streamline the discharge process
  • Completing housing paperwork for patients and answering questions related to housing applications and documentation 
Food Insecurity

Nearly 30 million Americans live in communities underserved by supermarkets or other healthy food retail, according to a recent study by the United States Department of Agriculture. Without proper nutrition, patients are not able to easily manage medical conditionsThe Health Affairs study found the following methods that ACOs have been using to address food insecurity;

  • Offering assistance to help patients enroll in public programs like Suplemental Nutrition Public Programs by helping them complete paperwork and the overall enrollment process
  • Partnering with local food banks and farmers markets to offer subsidized produce to patients at reduced costs
  • Creating unique solutions, like market days in the parking lots of local community centers, or working with and funding food banks to prepare fresh and healthy meals each day for patients

By meeting the needs of their patients, ACOs can provide better care for their populations. Once basic needs like proper food, shelter, and transportation are met, patients can easily focus on their health with less social stressors.  


Even though ACOs see the benefits of investing in SDOH, such as improved health outcomes, cost savings, and improvements in detecting needs, ACOs are still facing certain challenges. A few of these challenges are having a lack of data, the uncertainty of having a return on investment (ROI) for interventions, creating partnerships with the right community partners, and implementing standardized workflows between the ACOs and their partners. In order to improve these benefits, it is required to have close collaboration between stakeholder groups, including providers, public agencies, payers, and community partners, as well as to choose the right technologies to underpin these efforts.  

While ACOs continue to grow and become more involved in the SDOH, it’s important that this remains a key topic in public healthcare discussions, and we’re very excited to see the role that Netrin plays in driving meaningful change. Netrin Health offers a variety of services including the added benefits of our interdisciplinary care team to help support primary care practices and their patients in regards to SDOH. 

For instance, Netrin Health helps practices embed Z Codes into EHR using a screening tool that documents SDOH data which helps identify all patients with risk factors. Netrin’s care managers help these patients improve and support their SDOH needs while making sure that all SDOH interventions are closely monitored. 

For further details about our programs, please contact us today. 

Adler, N. E., Cutler, D. M., Fielding, J. E., Galea, S., Glymour, M. M., Koh, H. K., & Satcher, D., 2016. Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care. NAM Perspectives.

Islam, M. M., 2019. Social Determinants of Health and Related Inequalities: Confusion and Implications. NCBI.

Murray, G. F., Rodriguez, H. P., & Lewis, V. A. ,2020. Upstream With a Small Paddle: How ACOs Are Working Against the Current to Meet Patients’ Social Needs: A study of how some ACOs are attempting to address patients’ social needs. Health Affairs.

2021. Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH). Department of Health & Human Services Centers for Medicare & Medicaid Services.

January 28, 2020. How ACOs Are Identifying & Addressing Social Determinants of Health. Collective Medical.

Fraze, T., Lewis, V. A., Rodriguez, H. P., & Fisher, E. S., 2016. Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients. NBCI.