Targeting the social determinants through intervention, education


Studies have long tied social, environmental and economic factors to poor health and reduced access to care. Hackensack Meridian Health CEO Robert Garrett discusses how the New Jersey-based system made addressing the social determinants of health a top priority, and how he and his team are getting it done.

Can you talk about the genesis of your comprehensive SDOH program?

We understand that the path to better outcomes, more equity in healthcare and more value in care delivery depends greatly on developing and executing a robust strategy to screen patients for social needs. We believe this is the best way to address a fundamental failure in American healthcare: your ZIP code too often determines the state of your health.

Focusing on SDOH is one of the network’s seven strategic priorities and involved hiring new leaders, including Nicole Harris-Hollingsworth, an expert in community and population health. We also hired 25 community health workers—nonclinical staff with contextual expertise and extensive ties to the community—who are an integral part of the program’s success.

A key for all health organizations is to assess the needs unique to your community. Our network determined five priorities: food, housing, transportation, caregiver support and mental health/substance abuse treatment.

What were some of the program’s early initiatives, and how has it evolved

We understood that clinicians needed the screening process to be as easy as possible, so we built it right into our electronic health record system. In October 2018, the network started screening Medicare and Medicaid patients in a targeted region in New Jersey. When the federal pilot ended, the network had screened more than 100,000 patients and made 6,000 referrals to community services based on need. The initial results were so compelling that we prioritized expansion throughout the network, which has 17 hospitals and more than 500 patient care locations. The network also learned that to succeed, there needed to be team members beyond physicians who could conduct the assessment. Essentially, there are two approaches to reaching at-risk patients: at a point of contact in the network, and through member data provided by Horizon Blue Cross Blue Shield and other insurers through our Healthy Connections program.

Community health workers play a vital role; it’s like having a healthcare personal assistant. Additionally, the community health workers can log important information directly into the EHR regarding a patient’s social needs. That data is used to drive community referrals, which the community health worker vets and relays to the patient using a platform called Unite Us.



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