Hospice and non-hospice palliative care providers have long assumed that they address social determinants of health (SDOH) simply by having an interdisciplinary team in place. While social workers, chaplains, volunteers, and others do tremendous work to meet the psychosocial and spiritual needs of patients and families, this is not the same as the SDOH work that is currently a focus of clinical and payment reform efforts, especially in the arena of value-based care. While holistic care is the “secret sauce” that post-acute care providers have leveraged for decades, work still needs to be done in this area for these providers to take their place in the evolving value-based care continuum.
Most of this work consists of formalizing and structuring what is being done already. Processes need to be established for assessment using validated tools for all patients, specifically in the areas of transportation, housing adequacy, nutrition, and health literacy. Standardized screens need to be administered on all to gather and assess equity and access data.
Accessing the Area Deprivation Index (ADI)
Data analysis of SDOH to identify areas of risk is vital, starting with accessing the Area Deprivation Index (ADI). Formal collaborations with community-based organizations to address needs must be established, as well as follow-up performed to ensure that those needs have been met. Community health workers could be invaluable members of the clinical team to assist with this assessment, navigation, and follow-up.
SDOH and equity measures need to be included in quality measurement, reporting, and improvement efforts. While this development needs to happen to structure post-acute care providers’ SDOH work, such organizations still stand as the best and most prepared provider groups to step in and deliver this level of care. Holistic, interdisciplinary intervention focused on the family as the drivers of care is what other aspects of healthcare are trying to achieve. Home-based, post-acute care providers are already there. If such providers do not step forward and claim this space by formalizing what they are doing, other providers may move in and take that space over.
“’Untapped’ Social Determinants to Build into Palliative Care Programs” by Holly Vossel, posted by Hospice News on September 19, 2023, and accessible at