Addressing the Social Determinants of Health: The Rhode Island State Innovation Model (RI SIM) Experience

Tumber M, Bunzli L, Rosenberg M
Source: R I Med J
Publication Year: 2019
Patient Need Addressed: Financial insecurity, Food insecurity, Homelessness/housing, Transportation, Trauma
Population Focus: Medicaid beneficiaries
Intervention Type: Best practices, Staff design and care management, Technology/innovation
Type of Literature: White

Addressing social determinants of health (SDOH) is important for improving health and reducing longstanding disparities in health and healthcare. There is growing interest in standardizing SDOH measures and assessment tools for clinicians to help improve health outcomes. In 2015, Rhode Island received a $20 million State Innovation Model Test Grant (RI SIM) from the Centers for Medicare and Medicaid Services (CMS) to carry out health system transformation and to improve population health. As a part of RI SIM’s work, state and community partners began the development of an integrated, coordinated, statewide social services directory infrastructure for addressing SDOH. The goal is to transition this project from resource directory development to a broader eReferral system over the next few years. Tracking referral outcomes will improve coordination of care and will also provide data on capacity of services and help to direct policy and funding allocation decisions at the state level.

Insights Results

Overview of article/program

  • This article describes background, planning, and early lessons learned from the Rhode Island State Innovation Model (SIM)
  • Rhode Island’s State Innovation Model (SIM) used public process to identify actionable steps to improve coordination between state agencies and community partners to better understand the drivers of risk and to ultimately facilitate improved care management. One of the identified steps was to incorporate SDOH into risk algorithms and subsequent care management as a way to improve patient outcomes
  • RI SIM’s Unified Social Service Directory (USSD) focuses on connecting resource data from 2-1-1 to the various practices and organizations that need it in a way that can support existing workflows. The USSD provides the state with an integrated, coordinated infrastructure for addressing SDOH, but first, maintaining a statewide database of community-based organizations, services and public benefits. The current goal of the program is to transition this project from resource directory development to a broader eReferral system. Alignment of community and state findings will be instrumental to this expansion
  • Initiatives in other states included in this article are:
  • California – 2-1-1 San Diego: Connecting Partners through the Community Information Exchange (CIE) is a cloud-based platform designed to allow multiple health and social service providers to see a patient’s interaction across systems, agencies and community services. The CIE enables participating providers to better understand a client’s interactions with health and community services and improves care coordination for vulnerable patients. The CIE includes a social risk assessment tool, provides alerts, and facilitates connections across multiple agencies and providers. Results of the platform include reduction in calls to EMS and improved housing
  • North Carolina’s NCCARE360 is the first statewide coordinated care network to electronically connect those with identified needs to community resources and allows for a feedback loop on the outcome of that connection. Community partners will have access to a robust statewide resource directory that will include a call center with dedicated navigators; a data team verifying resources; and a shared technology platform that enables healthcare and human service providers to send and receive secure electronic referrals in real-time, securely share client information, and track outcomes


    • Common SDOH domains for measurement tools are: 1) Housing instability (e.g., homelessness, poor housing quality); 2) Food insecurity; 3) Transportation needs, both medical and non-medical in nature; 4) Utility needs, specifically screening for difficulty paying utility bills; and 5) Interpersonal safety related to intimate partner violence, elder abuse and child abuse
    • In SIM’s discussion around SDOH screening, 2 important takeaways emerged: 1) Some provider entities had begun to employ SDOH screening tools within their practices, indicating an opportunity to use common data elements to track the results of the screening to enable systematic data collection and monitoring of SDOH. Specifically, the working group proposed the use of Z-codes, statewide insurance billing codes, to document meta-identified SDOH; and 2) Some providers were reticent to screen for SDOH because they felt ill-equipped to respond to any social needs that became apparent

    Key takeaways/implications

    • Major lessons learned from the RI SIM include: 1) SDOH Screening processes need to be universal. To avoid stigmatizing anyone, and to avoid dangerous assumptions about patients. it is important to screen all patients, not just those thought to be “high risk”; 2) Information technology needs to be an integral part of the planning process. Social services and clinical settings often have different systems (or none at all) so addressing the quality and cost of the data connections they need is a crucial step; 3) To screen for SDOH, organizations need high-quality referral resources, prompt access to those resources (knowing who/what/where they are and the ability to see if the resource is available before the connection is made), and the ability to track the referral process and close the loop between the referring provider, the service provider, and the patient; 4) If possible, screening tools should be the same within a health system, but if they cannot be identical, they should be similar enough using common domains to help align quality measures, reporting, and search terms in common directories; and 5) The existence of multiple databases in an organization or health system, which all need to be updated, is burdensome to users. Aligning to a single database, and combining resources to update it, is a much more efficient use of time and money