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How ACOs Are Identifying & Addressing Social Determinants of Health

Managing and improving health outcomes means more than simply ensuring access to quality medical care. For patients affected by social determinants of health (SDOH), addressing nonmedical needs is critical to improving outcomes as medical care is estimated to account for only 10-20 percent of the modifiable contributors to health outcomes.

Accountable care organizations (ACOs) are responsible for the total cost and quality of care for a defined population of beneficiaries. Finding solutions for nonmedical needs can help ACOs reduce costs while improving clinical outcomes.

How ACOs Identify Patients Affected by Social Determinants of Health

A qualitative Health Affairs study reported two common methods for identifying patients with nonmedical needs. In the first method, patients were identified by primary care providers or through the use of a health assessment. The second method identified patients through care transformation programs. Some ACOs analyzed hospital utilization patterns or had staff in emergency departments. Others identified nonmedical needs during the use of quality improvement programs for things like chronic conditions.

An ACO toolkit released by the Centers for Medicare & Medicaid Services (CMS) found that many ACOs embed risk assessment tools into electronic health record (EHR) systems, allowing clinicians to screen patients at the point of care. This assessment data can also help ACO staff to establish priorities and guide interventions.

Approaches to Addressing Social Determinants of Health

The Health Affairs study found two main approaches ACOs take to address a patient’s nonmedical needs.

The first approach is working with patients one-on-one to meet individual needs. In an interview with The Commonwealth Fund, the lead author of the Health Affairs study offered up diabetes as an example. If a patient doesn’t have reliable electricity to keep their insulin cold, an ACO might work with a non-profit organization to fund that patient’s electricity for a given time.

The second approach ACOs take is a targeted approach to address a specific issue like food insecurity or transportation. An ACO might give patients public transportation passes or work with a food bank to ensure beneficiaries have access to nutritious meals.

The CMS toolkit reported several strategies different ACOs use to address SDOH. These included embedding tools into EHRs, building tools to identify community partners and make referrals, and developing community partnerships.

What Nonmedical Needs Are ACOs Addressing?

The Health Affairs study found that transportation, housing, and food insecurity were the three most common nonmedical needs that ACOs are addressing. Leaders of the 32 studied ACOs reported that these needs are common among their populations and affected how beneficiaries engage in medical care. ACO leaders also suggested that they had the potential and available resources to address these issues.


Transportation is a common barrier to receiving timely care. While ACOs in suburban or rural areas may experience more challenges, here are a few ways that ACOs have addressed the need for reliable transportation, according to the Health Affairs study:

  • Collaborating with transportation companies in the community
  • Providing public transportation passes either on a one-time or monthly basis
  • Developing new programs, such as mobile apps, allowing patients to request transportation


Approximately 3.5 million people in America experience homelessness each year according to a report by the National Center on Family Homelessness. Here are some of the ways that housing needs have been addressed by ACOs:

  • Developing partnerships with external housing agencies
  • Working with public health or other community agencies
  • Developing solutions like negotiating substance use requirements to allow patients to first receive housing and then begin treatment
  • Negotiating with a housing agency to designate beds for ACO patients post-discharge

Food Insecurity

Nearly 30 million people live in areas with limited access to supermarkets. Without proper nutrition, patients can’t easily manage medical conditions. The Health Affairs study found the following methods that ACOs have used to address food insecurity:

  • Offering assistance to help patients enroll in public programs like SNAP
  • Partnering with local food banks
  • Creating unique solutions, like market days in the parking lot of a local community center or working with a food bank to prepare fresh and healthy meals each day

By meeting the needs of beneficiaries, ACOs can better care for their populations. Once basic needs like proper food, shelter, and transportation are met, patients can shift their focus towards their health. The Social Determinants of Health report found several benefits of investing in SDOH, including improved health outcomes, decreased cost of care, and improvement in detecting needs. 

Brittany Eastman
Content Marketing Specialist