1. Module #1: What are the Social Determinants of Health (SDoH)?
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3. HCDI Overview HCDI-SAN Learning Library: Overview
HealthCare Dynamics, International – founded and led by clinicians
25+ years supporting CMS quality and population health programs
NICHE: Policy to Practice Strategy focused on health care delivery systems and the quality/cost for vulnerable populations
Customized learning and action platforms focused on clinicians, patients and health care systems
HCDI-SAN Learning Library: Overview
Social Determinants of Health (SDoH)
The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities
These social factors may also affect the patient’s ability to self-manage and adhere to their shared decisions.
Looking at SDoH data can help practitioners better recognize the root causes that affect population health.

4. Learning Objectives: Social Determinants of Health
Upon completing review of this presentation, the participant will be able to:
Define the different SDoH
Explain how inequities in the SDoH affect health outcomes and influence health disparities
Demonstrate knowledge of health equity
Expand their knowledge base concerning of resources available to those suffering from SDoH
Identify strategies to increase health equity in local communities

5. Overview: Social Determinants of Health
SDoH also refers to the bigger set of forces that shape the conditions of daily life of an individual.
These forces can be social norms, culture, social practices, economic policies, developmental agendas along with political systems of any state/nation
SDoH are considered as the root cause of our health and disease.
Often times it is also known as the ‘cause of the cause’.

6. HCDI-SAN Social Determinants of Health Goal: Health Equity
The HCDI-SAN goal in analyzing the SDoH, is to ensure clinicians, especially those serving vulnerable populations understand Health Equity and the importance of addressing the social determinants of health as they achieve clinical transformation to actively participate in the Quality Payment Program (QPP). We aim to support practices to:
Address the social factors that impact clinical outcomes
Improve practice care coordination methods
Adopt population specific needs
Collect REaL data
Close the gap between communities and health care delivery systems
Improve health promotion and the prevention/ management of chronic diseases
Promote culturally and linguistically appropriate person centered care
Provide shared decision-making and enhanced access to healthcare services

7. HCDI-SAN Social Determinants of Health Goal: Health Equity

8. Social Determinants of Health Goal: Health Equity
Across the nation, gaps in health are large, persistent and increasing. Health equity means everyone has a fair and just opportunity to be healthier.
It acknowledges that it's hard to be healthy without access to good jobs, homes and schools. It requires a concerted effort to increase opportunities to be healthier for everyone—especially those with the greatest obstacles.

9. Community Resources: Social Determinants of Health
Whether it’s access to food, transportation, financial services or education, addressing social determinants is a critical component of both quality of care and quality of life. Aunt Bertha is deploying this comprehensive approach, powered by technology, to help lead the way for patients in need and the people who serve them.

10. Learning In Action: “Food For Thought”
How might having data on patient SDoH conditions affect how your office coordinates healthcare for patients?
How can your practice incorporate SDoH collection and assessment into your workflow?
Do you think that SDoH (i.e. food insecurity, transportation, literacy) are common among your patients?
Think of a recent patient case in which SDoH might possibly have contributed to a problem or a poor health outcome?
What resources are available in your community to help address issues that are caused by SDoH?

11. Questions? Uchenna Okoli SDoH@hcdi.com 301-552-8803 www.hcdi.com
For more information on TCPI SANs please use this link:

12. Learning & Action Network Acronym Guide:
AAPM: Advanced Alternative Payment Models
APM: Alternative Payment Models
CEHRT: Certified Electronic Health Record Technology
CFYH Tool: ‘Caring for Your Health’ Social Determinants Indicator Tool
CMS: Centers for Medicare & Medicaid Services
HCDI: HealthCare Dynamics International
LAN: Learning and Action Network
MACRA: Medicare Access and CHIP Reauthorization Act
MIPS: Merit Based Incentive Payment System
PTN: Practice Transformation Network
QPP: Quality Payment Program
REaL Data: Race Ethnicity and Language Data
SAN: Support and Alignment Network
SDoH: Social Determinants of Health
TCPI: Transforming Clinical Practices Initiative