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Project Title:

Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation's Health
PIN: HMD-HCS-16-09        

Major Unit:

Health and Medicine Division

Sub Unit: Board on Health Care Services

RSO: Mitchell, Abigail

Subject/Focus Area: Behavioral and Social Sciences; Health and Medicine

Project Scope
An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will be developed to examine the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes and to address major challenges facing the U.S. health care system.  These challenges, include persisting disparities in health outcomes among vulnerable subpopulations, often defined by age, race, ethnicity, sex, gender identity, disability status, sexual orientation, socioeconomic status, family caregiver status, immigrant status, and geographic location. The committee will discuss: 1) approaches currently being taken by health care providers and systems, and new or emerging approaches and opportunities; 2) current roles of different disciplines and organizations, and new or emerging roles and types of providers; and 3) current and emerging efforts to inform the design of an effective and efficient care system that improves the nation's health and reduces health inequities. In creating its report, the committee will consider the:

1.     Current scope and conceptual underpinnings of health-related social needs care, including: a) roles of providers such as social workers, gerontologists, physicians, psychologists, nurses, community health workers, and trained volunteers; b) linkage to community-based organizations and services; and c) the role of hospital community benefits. 

2.     Current state of the social needs care workforce in preventing, controlling, and treating health-related conditions (e.g., disciplines providing social needs care and their professional qualifications, breadth of settings, and roles for such care, including administrative, policy, and research roles; current training for each discipline related to provision of social needs care; and projected workforce needs to meet demographic changes).

3.     Evidence of impact of social needs care on patient and caregiver/family health and well- being, patient activation, health care utilization, cost savings, and patient and provider satisfaction.

4.     Opportunities and barriers to expanding historical roles and leadership of social workers in providing health-related social needs care, and the expanding role of other types of providers, such as gerontologists.

5.     Emerging and evidence-based care models that incorporate social workers and/or other social needs care providers in interprofessional care teams across the care continuum (e.g., acute, ambulatory, community-based, long-term care, hospice care, public health, care planning) and in delivery system reform efforts (e.g., enhancing prevention and functional status, care management, and transitional care; improving end-of-life care; integration of behavioral, mental, and physical health services).

6.     Initiatives to improve population health and reform health care financing that incorporate social needs care (i.e., payments tied to quality metrics and alternative payment models, such as Accountable Care Organizations, bundled payments, managed long-term services and supports, and Accountable Health Communities).

7.     Realized and potential contributions of social needs care to make health care delivery systems more community based, person- and family/caregiver-centered, and responsive to social and structural determinants of health, particularly for vulnerable populations and communities, such as older adults and low-income families.

8.     Opportunities for advancing the integration of social needs care services within community and health care delivery settings, such as expanding and improving interprofessional education, educating health care providers, payers, and patients about the benefits of social needs care services, and ensuring adequate reimbursement by public and private payers.

9.     Kinds of transdisciplinary research needed to understand the complex interplay of psychosocial and environmental factors on health, and best to inform efforts to develop policies and practices that lead to improved health outcomes.

The committee will make recommendations on how to: 1) expand social needs care services; 2) better coordinate roles for social needs care providers in interprofessional care teams across the continuum of clinical and community health settings; and 3) optimize the effectiveness of social services to improve health and health care. Recommendations may address areas such as integration of services, training and oversight, workforce recruitment and retention, quality improvement, research and dissemination, and governmental and institutional policy for health care delivery and financing.

The approximate start date for the project is April 1, 2018. A report will be issued at the end of the project in approximately 18 months.

Project Duration: 18 months    

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Committee Membership
Committee Membership

 Meeting 1 - 07/16/2018


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