Social Determinants of Health

Our mission to build strong, healthy communities goes beyond clinical care. Up to 80 to 90 percent of a person's health is tied to factors other than clinical care.¹ These factors, known as the social determinants of health, include nutritious food, access to care, safe housing, reliable transportation, and community supports.

These underlying drivers of health impact every part of our physical, mental, and social well-being. When they work against someone or are left unaddressed, they create health inequalities — which lead to worse outcomes and more expensive care.

That’s why our person-centered model of care goes beyond the doctor’s office. We ensure that our members have the critical support and services they need, so they can make important lifestyle changes and lead healthier, more productive lives.

Our areas of focus

We focus our efforts on:

• Education, including early childhood development, high school graduation or GED completion, higher education, and enhancement of language and literacy skills.
• Health and health care, improving health literacy with self-management goals and supports and access to integrated primary care.
• Neighborhood and recreational environment, including access to healthy food, quality housing, low crime and violence, and safe environmental conditions.
• Social and community context, including civic participation and minimizing the stigma of discrimination due to incarceration and/or substance use histories.
• Economic stability, including steady employment, food security, stable housing, and a lack of poverty.

Our work with social determinants

No managed care company can expect to influence every single social determinant. Many are larger societal factors that are out of our control. But by focusing on person-centered member outreach and connecting members to resources to promote their knowledge and skills for a healthier lifestyle, we can still make a lasting difference in their lives.

Our approach of universal screening for social determinants of health allows us to quickly identify a member’s status as either crisis, vulnerable, or stable. We can then take appropriate action, such as:

• Referring to a case manager.
• Connecting with a local food bank.
• Using social platforms such as Aunt Bertha to help find shelter.
• Working with them via our AmeriHealth Caritas Community Care Management Team (CCMT), a frontline ally in addressing the negative factors in our members’ lives. Comprised of a licensed nurse, a licensed social worker, and community health navigators, our CCMTs reach out to the highest risk population with complex care needs.

Other specific programs include:

• Job placement and readiness: Steady income is a key determinant, so we offer several training and GED programs to help members transition into the work force, or into the next step in their careers. 
• Healthy living programs: AmeriHealth Caritas District of Columbia (DC) provides numerous classes, such as exercise and healthy cooking, as well as additional benefits like gym memberships and membership in the Capital Bikeshare program. All are available at no cost to members.
• Medical nutrition therapy: Keystone First has partnered with the Metropolitan Area Neighborhood Nutrition Alliance (MANNA) to deliver meals and provide nutrition counseling to members who experience food insecurity and are living with chronic medical conditions such as diabetes.

1. Magnan, S. "Social Determinants of Health 101 for Health Care: Five Plus Five." NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. 2017. https://doi.org/10.31478/201710c