Medicaid ACO Checklist for Social Determinants of Health

Publication Year: 2019
Patient Need Addressed: Food insecurity, Homelessness/housing, Patient satisfaction/engagement
Population Focus: Medicaid beneficiaries
Intervention Type: Best practices
Type of Literature: Grey


Insights Results

Overview of article

  • Medicaid Accountable Care Organizations (ACOs) provide an opportunity to address the social determinants of health (SDOH) among the Medicaid population. Addressing these factors improves health, reduces disparities in healthcare and access to care, and reduces long-term healthcare costs. A new section on SDOH is now part of the toolkit, “Medicaid ACO Checklist for Advocates,” giving concrete best practices for addressing SDOH at the encounter, organizational and community levels. In each section, current best practices from states at the leading edge of this work are included, with links to their work. The following information outline the following levels that ACOs should address as part of their SDOH-related initiatives


  • Encounter level: Regularly assess individual patients’ social and economic needs with screening tools. Provide appropriate referrals to social service organizations, navigation assistance for accessing social services, and follow-up to see if patients received the needed services
  • Organizational level: Include requirements that ACOs implement a range of specific programs that directly address social determinants of health, such as supportive housing or food and nutrition interventions. Include quality measures related to addressing the SDOH
  • Community level: Regularly assess the social service needs of the community, including using a community health needs assessment (CHNA) and community health improvement plan. Assess the effectiveness of ACO’s community partnerships