Social Determinants of Health Overview
Neighborhood and Built Environment
- Availability and Quality of Housing
- Transportation
- Safety
- Opportunities for Active Living
- Access to Healthy Food Options
- Healthy Work Environments
Social and Community Context
Education
Economic Stability
Health and Health Care
An individual’s access to health care, including preventative services, can lead to better health outcomes. To understand the ways healthcare impacts the health of a community, it is important to look at conditions such as:
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Our ability to have good physical, social, and mental health is easier when the health care services are close to where we live, affordable, and of high quality. People who have both health insurance and easy access to care are more likely to receive preventative services like flu shots, screenings, and vaccines. Preventative services reduce health care spending through early identification of diseases and risk factors. Many individuals struggle to receive care because appointments are unavailable, or they are unable to take time off of work. To improve access to care it’s important to address barriers such as lack of health insurance, language barriers, disabilities, transportation to care, and appointment availability. (Health People, 2020 and County Health Rankings, Access to Care)
Understand Local Conditions
Chartbook on Access to Health Care
This report summarizes disparities in health care access across common metrics.
Source: Agency for Healthcare Research and Quality; US Department of Health and Human Services
County Health Rankings and Roadmaps
A breakdown of the overall county health rankings based on several health factors designed for uninsured folks.
Source: US Census Bureau Small Area Health Insurance Estimates
Population Data By County
This map gives the changes in access to health care by county. The most recent data is 2014.
Source: Open Data NetworkChange local conditions
Adolescent Health Initiative: Starter Guides
This website contains toolkits that offer ideas and actionable steps to improve adolescent care.
Source: University of Michigan Adolescent Health Initiative
Paving the Road to Good Health Strategies for Increasing Medicaid Adolescent Well-Care Visits
How Early and Periodic Screening, Diagnostic and Treatment (EPSDT) supports adolescent health and reduces health care costs.
Source: Centers for Medicare and Medicaid Services
Connecting Those at Risk to Care: The Quick Start Guide to developing Community Care Coordination Pathways a companion to the Pathways Community HUB Manual
A reference guide that explore how community care coordination initiatives use pathways and a pay-for-performance methodology to connect at risk individuals to needed healthcare.
Source: Agency for Healthcare Research and Quality; U.S. Department of Health and Human Services
Getting Started with NCQA Patient-Centered Medical Home Recognition
This toolkit explores the Patient-centered Medical Home model.
Source: National Committee for Quality Assurance
Bright Futures Guidelines and Pocket Guide
Guidelines for health care professionals on preventative healthcare recommendations for children and adolescents.
Source: American Academy of Pediatrics
Health Care Transition Resources
This website contains multiple toolkits and guides for health care providers, youth and families and policy makers related to helping youth and young adults transition from pediatric to adult health care.
Source: Got Transition
Tools for Implementing a Patient Centered Medical Home
Tools and resources for implementing the patient-centered medical home (PCMH) model in primary care to improve access to healthcare.
Source: U.S. Department of Health & Human Services
Rural Hospital-Health Clinic Integration
A strategy to improve the accessibility and delivery of healthcare within rural hospital networks.
Source: American Hospital Association
Cities Promoting Health Care Coverage for Children and Families
Document illustrating municipal action plan for city leaders to initiate health care access for children and families.
Source: National League of CitiesLeverage SDoH Intersection Examples
Sixteenth Street Community Health Center
Example of how a federally qualified health center expanded focus to address housing, employment, and environmental determinants of health.
Source: Institute for Alternative Futures
myCommunity Connect Center
Located in a low-income neighborhood in Phoenix, the center houses a broad range of health and social services under one roof and works in improving the health and economic stability of vulnerable families.
Source: Shelter Force
Safe Station
Manchester Fire Stations are designated safe environment for the individuals seeking assistance looking for treatment to start their path to recovery from heroin.
Source: City of Manchester
The Davies Project
Resource in Mid-Michigan organizing how families and children can reach their medical appointments through ride sharing.
Source: The Davies Project
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According to the Institute of Medicine, quality healthcare is: 1) Safe for patients; 2) Effective and based on scientific best practices; 3) Patient-centered, meaning it is respectful and responsive to patient needs and preferences; 4) Timely and free of long wait times; 5) Efficient; and 6) Equitable, providing quality care to everyone regardless of gender, race/ethnicity, income, geographic location, etc. (Institute of Medicine, 2001).
Understand Local Conditions
Healthcare Quality Indicators
Standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.
Source: Agency for Healthcare Research and Quality; U.S. Department of Health and Human Services
Health Care Quality Framework
Health Care Quality Framework outlined by the Organization for Economic Co-operation and Development.
Source: Organization for Economic Co-operation and Development
Measuring Health Care Quality: An Overview of Quality Measures
Overview of how to measure healthcare quality and what types of measurements should be included in a healthcare assessment.
Source: Families USA
Sixteenth Street Community Health Centers: Quality of Health Indicators
Example of quality health indicators measured by a community health organization.
Source: Sixteenth Street Community Health Center
Rural Healthcare Quality
Health Quality indicators for rural communities.
Source: Rural Health Information HubChange Local Conditions
Healthcare Quality Improvement Essentials Toolkit
Tools and templates to launch a successful quality improvement project and manage performance improvement.
Source: Institute for Healthcare Improvement
National Culturally and Linguistically Appropriate Services Standards
How to make culturally and linguistically appropriate improvements to standards of care.
Source: U.S. Department of Health and Human Services
Patient Safety Culture Tool
A guide for healthcare organizations who wish to develop an action plan to improve patient safety culture.
Source: Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality Toolkits
A variety of research-based tools and resources for health care organizations and providers to make care safer.
Source: Agency for Healthcare Research and Quality, US Department of Health and Human Services
Using the Healthy Hospital Food, Beverage, and Physical Activity Environment Scans
A step by step guide to enhance the health environment of a hospital.
Source: Centers for Disease Control and Prevention
Quality Through Collaboration: The Future of Rural Health
Federal document highlighting the challenges rural health networks face and how to the government should address those conditions.
Source: Rural Health Information Hub; The National Academies of Science and Engineering
MAP 2018
The MAP workgroup focused on identifying the best available measures of rural healthcare and providing recommendations from the rural perspective.
Source: National Quality ForumLeverage SDoH Intersection Examples
Using the Healthy Hospital Food, Beverage, and Physical Activity Environment Scans
A step by step guide to enhance the health environment of a hospital.
Source: Centers for Disease Control and Prevention
Healthy Androscoggin
Non-profit organization working to support physical activity, healthy eating, substance use, tobacco-free lifestyles and preventing lead poisoning.
Source: Healthy Androscoggin
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Everyone has the ability to take a role in managing their health and the health of those in their care. However, with the increasing complexity of health information and health care settings, most people need additional information, skills, and supportive relationships to meet their health needs. Health literacy includes relevant information, skills, and relationships needed to promote health.
Understanding Local Conditions
Quick Guide to Health Literacy
This fact sheet explains how health literacy is associated with health outcomes.
Source: U.S. Department of Health and Human Services
Health Literacy Tool Shed: All Aspects of Health Literacy Scale - AAHLS
A tool for measuring functional, communicative and critical health literacy in primary healthcare settings.
Source: Chinn & McCarthy
Health Literacy Questionnaire
Assessment tool for measuring health literacy.
Source: Osborne, Batterham, Elsworth, Hawkins, & Buchbinder
A Critical Review of Population Health Literacy Assessment
This review examines currently available health literacy assessment tools to identify how well suited they are in addressing health literacy beyond clinical care settings and the individual.
Source: PubMed CentralChange Local Conditions
Health Literacy Universal Precautions Toolkit
A toolkit to help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Source: Agency for Healthcare Research and Quality
Toolkit for Making Written Material Clear and Effective
A toolkit to help make printed materials easier for people to read, understand, and use.
Source: Centers for Medicare and Medicaid Services
Ten Attributes of Health Literate Health Care Organizations
Ten exemplifying attritubes health literate health care organizations provide for their patients to have optimal access and range of their health care services.
Source: Institute of Medicine of the National AcademiesLeverage SDoH Intersection Examples
Community Health and Literacy Center
Example of different organizations working together to bring about improved access to health care and promoting recreation and literacy opportunities.
Source: Community Tool Box
In It Together Health Literacy Project
A training initiative designed to help health professionals incorporate health literacy approaches and strategies into the services they provide, with the goal of improving engagement and retention in HIV care and treatment.
Source: Target HIV
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Data So Data Source FastStats Healthcare and Insurance
Databases and reports on various healthcare and insurance topics.
(Centers for Disease Control and Prevention)Healthcare Effectiveness Data and Information Set (HEDIS)
The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used sets of healthcare performance measure in the United States.
(National Committee for Quality Assurance)Data Resources
Latest statistical portraits of how healthcare is delivered in the United States.
(Agency for Healthcare Research and Quality)Rural Data Explorer
Communities can select from a wide range of data on health disparities, health workforce, demographics, and more.
(Rural Health Information Hub)