INTEGRATING SOCIAL NEEDS CARE INTO THE DELIVERY OF HEALTH CARE TO IMPROVE THE NATION’S HEALTH FOR OLDER ADULTS

Abstract An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine examined 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 a number of factors including age. Presenters will discuss and provide recommendations in the following areas: 1. evidence of impact of social needs care on patient and caregiver/family health and wellbeing, patient activation, health care utilization, cost savings, and patient and provider satisfaction; 2. opportunities and barriers to expanding historical roles and leadership of social workers in providing health-related social needs care 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); and 3. 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. Examples for each of the three areas will also be presented.


What brings us here today?
"Older adults have unique needs.
To prevent harm to older adults, improve health outcomes, and lower overall costs, health care systems must adopt evidence-based models and practices that deliver better care to our rapidly aging population across all settings, including the home and community." The National Academies today ▪ An independent, non-profit organization -Not part of federal government -Must raise funds for every activity; typical sponsors include philanthropic foundations, state and federal agencies, or congressional appropriation ▪ Two types of activities: -Consensus studies and reports An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will 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.
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.

Statement of Task
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.

Approach
• Collect information. Sources that informed the committee's work included peer-reviewed and "gray" literature, websites highlighting social care-health care integration programs, invited presentations at public meetings.
• Review and analyze the evidence base.
• Develop findings and recommendations.
• Summarize the evidence, findings, and recommendations in a report.
• Conduct external review of draft report.
• Finalize report reflecting committee consensus on findings and recommendations.

The Case for Integrating Social Care into Health Care Delivery
• Social factors-e.g., housing, food, and transportation-influence health. • The health care delivery system is traditionally focused on providing medical interventions to treat or prevent disease, not on addressing upstream social factors that contribute to illness and poor health care outcomes. • Addressing social factors as part of health care delivery is important for high-quality, high-value health care.
• Move to value-based health care • Growing body of evidence for how to do this • Active interest from multiple sectors • Need for a taxonomy and framework to organize discussion about these activities Why is this report important now?
• Everyone's health is affected by their social context, and everyone may experience social needs at some point in their life (e.g. following hospitalization, as we age) • For some individuals and communities these needs are multiple, chronic, and faced without resources -leading to disparities in health.
• Addressing social needs may improve health outcomes for many and be particularly important for addressing health disparities.

Health equity
Five Activities to Facilitate Integration