Industry Coverage icon

The Role of Social Determinants of Health in Value-Based Care Delivery

Four Steps to connecting "upstream" SDOH conditions to "downstream" outcomes.

Unlock a Free Sample
  • When considering cost optimization and service delivery efficiency, the business and IT often focus on population health outcomes, ignoring the holistic impact of the social conditions that are at the root cause.
  • Public health and healthcare leadership require a methodological approach that helps CIOs and the organization’s leadership accelerate the strategy design process that aligns ‘upstream’ social conditions with ‘downstream’ outcomes.

Our Advice

Critical Insight

  • Using an industry-specific thought model has many benefits and is central to organizational priorities simultaneously focused on enabling and enhancing the triple aim toward value-based care delivery and cost optimization.
  • It is critical to understanding, modeling, and communicating the operating environment and the direction of the organization, but more significantly, to enabling measurable top-line organizational outcomes and the unlocking of direct value.

Impact and Result

Main learning objectives:

  • Develop awareness about the role of social determinants of health (SDOH) in value-based care delivery and how they are connected to "downstream" health outcomes.
  • Learn four critical steps to connecting "upstream" SDOH conditions to "downstream" outcomes toward cost optimization and accountable care participation.
  • Discover leading data sources and curated metrics that can be used in building prediction models for nowcasting, forecasting, and scenario modeling on beneficiary and overall population health.

The Role of Social Determinants of Health in Value-Based Care Delivery Research & Tools

1. A deck that provides a thought model and four critical steps to connecting "upstream" social determinants of health conditions to "downstream" health outcomes toward cost optimization and accountable care participation.

The purpose of this deck is to provide an overview of the role of social determinants of health (SDOH) as a primary approach to supporting the triple aim through value-based care delivery.

It is designed as a high-level overview to help healthcare and government industry members understand the connection between "upstream" social, economic, and environmental conditions – the “causes of the causes” of ill health – and their association with "downstream" health outcomes.

Unlock a Free Sample

The Role of Social Determinants of Health in Value-Based Care Delivery

Four Steps to Connecting "Upstream" SDOH Conditions to "Downstream" Outcomes

Table of Contents

Healthcare and Government Industry Practice

The Role of Social Determinants of Health in Value-Based Care Delivery

3 Analyst Perspective
4 Social Determinants of Health Defined
5 Social Determinants of Health – A Brief History
6 The Role of Social Determinants of Health in Value-Based Care Delivery
7 Leading Social Determinants of Health Frameworks
8 Roadmap
9 Emergent Public Health Practice – Upstream Defined
10 Current Public Health Practice – Downstream Defined
11 4 Steps to Connecting Upstream Social Conditions to Downstream Health Outcomes
16 Social Determinants of Health Thought Model
17 Metrics: Leading SDOH Data Sources & Curated Indicators
18 Establishing Baseline Metrics
19 Levels of Support and Next Steps
23 Bibliography
Appendices
28 Appendix 1.0: Social Determinants of Health – Leading Frameworks
31 Appendix 2.0: Glossary of Social Determinants of Health Data Sources
37 Appendix 3.0: Social Determinants of Health Data Indicators and Measures

Analyst Perspective

To successfully shift from a fee-for-service model of healthcare delivery to value-based care, cost optimization must take into consideration the "upstream" social, environmental, and institutional inequities that affect "downstream" individual and population health.

Within the past decade, the social determinants of health (SDOH) have been recognized as important, if not, key indicators of health outcomes. There is growing awareness that SDOH information improves whole-person care and lowers cost, and that unmet social needs negatively impact health outcomes.

For example, food insecurity correlates with higher levels of diabetes, hypertension, and heart failure; housing instability factors into lower treatment adherence; and transportation barriers result in missed appointments, delayed care, and lower medication compliance.

This Client Advisory Deck (CAD) provides an overview of the role of SDOH as a primary approach to supporting the triple aim through value-based care delivery.

It is designed to help healthcare and government industry members – population health practitioners in government settings, health insurers, healthcare providers, among other partners and stakeholders – to understand the connection between “upstream" social, economic, and environmental conditions – the social determinants of health known as the “causes of the causes” of ill health – and their association with “downstream" health outcomes.

It offers 4 steps to connecting “upstream" SDOH conditions to “downstream" outcomes and a hyperlinked repository to leading data sources and metrics.

Photo of Neal Rosenblatt, Principal Research, Director, Public Health, Info-Tech Research Group Neal Rosenblatt
Principal Research Director, Public Health
Info-Tech Research Group

Social determinants of health defined

Two key perspectives: the World Health Organization (WHO) and the United States

Two leading organizations – the World Health Organization (WHO) and the US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP) – define the social determinants of health as:

Social Determinants of Health Defined

The non-medical factors that influence health – the conditions of daily life that have an impact on a wide range of health, functioning, and quality of life outcomes and risks. (Source: WHO, “Social Determinants of Health” and US DHHS, “Healthy People 2030 Framework”)

Health Equity Defined

The absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically. (Source: WHO, “Social Determinants of Health”)

Examples of Social Determinants of Health

Examples of social determinants of health that drive health outcomes:

  • Healthcare access and quality
  • Education access and quality
  • Safe housing, transportation, and neighborhoods
  • Racism, discrimination, and violence
  • Job opportunities, income, and social protection
  • Access to nutritious foods and physical activity opportunities
  • Structural barriers
  • Polluted air and water
  • Language and literacy skills

Social determinants of health – a brief history

In 2005, the WHO’s Commission on Social Determinants of Health was established “to support countries and global health partners in addressing the social factors leading to ill health and health inequities.” The Commission’s aim was to “draw the attention of governments and society to the social determinants of health and in creating better social conditions for health, particularly among the most vulnerable people.”

The Commission’s report was delivered in 2008. It focused on three overarching recommendations:

  1. Improve daily living conditions
  2. Tackle the inequitable distribution of power, money, and resources
  3. Measure and understand the problem and assess the impact of action

In the US, the US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP) launched the Healthy People Initiative. Its origin was the 1979 Surgeon General’s landmark report titled “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” This report spawned a series of priorities for improving the nation’s health in 10-year increments. Today, Healthy People 2030 builds on knowledge gained over the past 4 decades and has increased focus on health equity, health literacy, and social determinants of health with a new focus on health and well-being for all – a primary focus of the value-based care delivery model.

One of Healthy People 2030’s 5 overarching goals is specifically related to the social determinants of health (SDOH): “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” In line with this goal, Healthy People 2030 features many objectives related to SDOH. These objectives highlight the importance of "upstream" factors – usually unrelated to healthcare delivery – in improving health and reducing health disparities.

Social determinants tend to be systemic, societal challenges – economic policies and systems, development agendas, social norms, social policies and political systems – that will be solved through long-term upstream investments and collaboration between government, the public sector, and private industry.

The social determinants of health have an important influence on health equity – defined as the “absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically.”

Examples of social determinants of health that drive health outcomes:

  • Healthcare access and quality
  • Education access and quality
  • Safe housing, transportation, and neighborhoods
  • Racism, discrimination, and violence
  • Job opportunities, income, and social protection
  • Access to nutritious foods and physical activity opportunities
  • Structural barriers
  • Polluted air and water
  • Language and literacy skills

The role of social determinants of health in value-based care delivery

Helping healthcare systems optimize performance

The likely origin of the value-based care (VBC) model is the Patient-Centered Medical Home (PCMH) that was first introduced by the American Academy of Pediatrics in 1967.

In 2007 – 2010, several value-based programs arose out of a bevy of seminal activity from the Institute for Healthcare Improvement’s (IHI) launch of the Triple Aim framework of 2007, the Medicare Improvements for Patients & Providers Act (MIPPA) of 2008, and the Affordable Care Act (ACA) of 2010.

This activity began a shift from a fee-for-service healthcare delivery model focused on volume of services to a value-based care model – one that centers on care quality and outcomes and a team approach to care.

And it is this shift that is significantly changing the way healthcare is delivered and reimbursed in the United States, and it is seen as a priority in many health systems worldwide.

Institute for Healthcare Improvement Triple Aim Framework

A three-pronged approach:
  1. Improving patient experience
  2. Reducing per capita costs of healthcare
  3. Improving the health of the population overall
Experience of care:
  • Assess overall health of communities served
  • Identify existing concerns or areas of risk
  • Assess overall mortality
  • Help patients navigate the healthcare system
  • Improve provider-patient communication
  • Create patient-centered care coordination teams
  • Track patient healthcare satisfaction
  • Establish quality improvement measures
Pyramid titled 'Triple Aim' with the base two points labelled 'Experience of Care' and 'Per Capita Cost', and the top point 'Health of a Population'. Health of a population:
  • Identify and address risk in communities preemptively
  • Understand patient healthcare use
  • Provide improved, patient-centered, coordinated, and accountable care
  • Design new models of care to better serve populations
  • Involve individuals and families when designing care models
  • Redesign primary care services and structures
  • Improve disease prevention and health promotion
  • Build a cost-control platform
  • Support system integration and execution
Per capita cost:
  • Improve population segmentation analytics
    • Aging population
    • Chronic health problems
  • Identify at-risk populations
  • Improve healthcare quality
  • Address community health concerns and needs

Achieving the Triple Aim is critical to the success of healthcare organizations that are moving toward value-based payment systems.

The Triple Aim encourages healthcare leaders to use strategies, such as Accountable Care Organizations (ACOs), to improve the health of their communities beyond the hospitals and clinics that make up the healthcare system. (Source: Institute for Healthcare Improvement, “IHI Triple Aim Initiative.”)

Leading social determinants of health frameworks

Leverage leading-edge industry standards and resources

Many countries, including the United States, Canada, United Kingdom, and Australia, recognize the importance of addressing social determinants of health as part of improving overall health and well-being.

Several frameworks have been developed to help communities, health professionals, and others begin to better understand and address a variety of factors that affect health.

Among the frameworks describing social determinants of health, these three – Healthy People 2030, ONC Interoperability Standards Advisory (ISA), and the BARHII Framework ‒ are the most highly specified and leading-edge.

  • Healthy People 2030 offers 5 key domains with specified objectives and comparison measures.
  • ONC Interoperability Standards Advisory (ISA) provides core data indicators, value sets and standards.
  • BARHII Framework establishes the relationship between "upstream" social, economic, and environmental conditions and "downstream" health outcomes.

Info-Tech Insight

Leverage leading-edge industry standards and resources to build interoperable SDOH indicator sets for comparison measurement, population and beneficiary health status assessment, and cost optimization.

1. Healthy People 2030

Pie graph of elements that contribute to healthy people.

Industry: Health and Human Services
  • Five key domains with specified objectives & comparison measures
  • (Source: US DHHS, “Healthy People 2030)

2. ONC SDOH ISA

Sample of the ONC's 2022 Interoperability Standards Advisory.

Industry: Health IT
  • Core data indicators (USCDI), value sets & standards
  • (Source: Office of the National Coordinator for Health IT, "Interoperability Standards Advisory)

3. BARHII Framework

Sample of the BARHII Framework

Industry: Public-Private Partnership
  • Establishes the relationship between upstream conditions and downstream outcomes
  • Illustrates the connection between social inequalities and health
  • (Source: Bay Area Regional Health Inequities Initiative, BARHII Framework)

Connecting "upstream" social conditions to "downstream" health outcomes: a roadmap

UPSTREAM 1
Metrics & Standards
2
Infrastructure & Architecture
3
Data Engineering
4
Analytics & Reporting
DOWNSTREAM
A bridge connecting a city with a green background on the left to a city with a red background on the right. Each suspension is a column header: '1 Metrics & Standards', '2 Infrastructure & Architecture', '3 Data Engineering', and '4 Analytics & Reporting'.
Emergent Public Health Practice

Characterized by:

  • Health Equity Considerations
  • Social Determinants of Health
    • Social Inequities
      • Individual Level
    • Systemic Inequities
      • Structural Level
    • Place-Based (Living) Conditions
      • Physical Environment
      • Social Environment
      • Economic / Work Environment
      • Services Environment
  • Leverage and use leading-edge industry standards and resources for comparison measurement
  • Ensure that your infrastructure supports your business and health information management needs
  • Establish a set of data architecture rules, policies, standards, and models
  • Optimize your data infrastructure and architecture
  • Get the right information to the right people at the right time
  • Formulate an enterprise reporting and analytics strategy
  • Deliver actionable business insights
  • Make faster decisions and predict future outcomes
Current Public Health Practice

Characterized by:

  • Health Risk Factors & Conditions
    • Disease & Injury
    • Risk Behaviors
    • Mortality

Info-Tech Insight

Use location-based data to identify high-risk individuals and communities and provide highly targeted early intervention support as a member of an Accountable Care Organization (ACO).

Emergent public health practice

"Upstream" social determinants

How do upstream determinants impact health and well-being?
Roadmap position and visual of 'Upstream social determinants' from the previous slide. Mekko chart of 'Determinants of Health' with 'Socioeconomic Environment 40%', 'Health Behaviour 30%', 'Healthcare 20%', and 'Physical Environment 10%'. Source: Hussein, T., and M. Collins, 2016.
Health equity considerations

Social Inequities

Individual Level
  • Age
  • Class
  • Education
  • Gender/Gender Identity
  • Race/Ethnicity
  • Religion
  • Sexual Orientation

Systemic Inequities

Structural Level
  • Government & Agencies
  • Law & Regulations
  • Organizations, Corporations & Businesses
  • Schools
  • Urban/Regional Planning

Place-Based Conditions

Physical Environment
  • Environmental Land Use
  • Hazards Exposure
  • Housing & Zoning
  • Redlining
  • Residential Segregation
  • Transportation Access
Economic & Work Environment
  • Employment
  • Income
  • Occupational Hazards
  • Structural Barriers

Social Environment
  • Class, Gender, Ethnicity
  • Social Capital
  • Social Cohesion
  • Violence
Services Environment
  • Education Access & Quality
  • Healthcare Access & Quality
  • Social Services

Social • Economic • Environmental Landscape

Up to 89% of health occurs outside of the clinical space through our genetics, behavior, environment, and social circumstances. (Source: GoInvo, 2020.)

Current public health practice

Roadmap position of 'Downstream social determinants' from the roadmap slide.

"Downstream" health outcomes

Characterized by a clinical landscape & aligned with a sick-care/fee-for-service orientation.

Downstream outcomes – risk behavior, morbidity, and mortality – focus attention on measures which have traditionally been within the scope of public health epidemiologic surveillance, analytics, and reporting.

Health & human services are often delivered in silos, making it difficult to provide coordinated person-centered, place-based care and assess effectiveness of service delivery.

Health Risk Factors & Conditions

Disease & Injury

  • Alzheimer’s Disease & Other Dementias
  • Cancer
  • Communicable Disease
  • Chronic Disease
  • Chronic Lower Respiratory Disease
  • COVID-19
  • Diabetes
  • Diarrheal Diseases
  • Heart Disease
  • Influenza and Pneumonia
  • Injury (Intentional & Unintentional)
  • Kidney Disease
  • Neonatal Conditions
  • Stroke

Mortality

  • Infant Mortality
  • Maternal Mortality
  • Life Expectancy
  • Suicide

Risk Behaviors

  • Alcohol Use
  • Drug Use
  • Low Physical Activity
  • Poor Nutrition
  • Sexual Behavior
  • Tobacco Use
  • Violence

Risk Behavior • Morbidity • Mortality

Visual of 'Downstream health outcomes'.

Info-Tech Insight

To improve the capacity and capability of public health service, shift focus upstream to drive primary prevention, core functions, and essential services. Leverage standard metrics for comparison. Use innovative technologies, such as Applied Artificial Intelligence (AAI), for data-enabled, automated, adaptive decision support as a service to predict outcomes through SDOH automated assessment and place-based intervention.

Four key steps to connecting "upstream" determinants to "downstream" outcomes

Metrics & Standards
  • Leverage and use leading-edge industry standards and resources for comparison measurement

Infrastructure & Architecture

  • Ensure that your infrastructure supports your business and health information management needs
  • Establish a set of data architecture rules, policies, standards, and models
  • Optimize your data infrastructure and architecture

Data Engineering

  • Get the right information to the right people at the right time

Analytics

  • Formulate an enterprise reporting and analytics strategy
  • Deliver actionable business insights
  • Make faster decisions and predict future outcomes

Roadmap from earlier with arrows pointing to steps 1 to 4.

Public Health Practitioners know that health is more than medical care, and they face several challenges in leveraging data to inform their strategy:
Address the issues:
  • Social determinants of health data can be difficult to collect and share.
  • While the evidence base on the social determinants has strengthened, the evidence base on what works needs to be strengthened and good practices developed and disseminated.
Overcome challenges:
  • Develop and implement innovative strategies to support core functions and essential services focused on key domains of social determinants.
  • Increase your organization’s capacity and capability as a public health service.

STEP 1: Metrics & Standards

Roadmap with an arrow pointing to step 1.

Leverage and use leading-edge industry standards & resources for comparison measurement.

Example: Healthy People 2030 objectives, indicators and measures.

Expanded table of 'Health People 2030 categories with examples for 'Education Access and Quality', 'Health Care Access and Quality', 'Economic Stability', 'Neighborhood and Built Environment', and 'Social and Community Context'.
Source: US DHHS, Healthy People 2030

— Example —

Apply the five domains of social determinants of health to public health core functions and essential services.

5 Domains • 45 Objectives • 123 Measures
  • Economic Stability
    • 5 Objectives
    • 9 Measures
    economic stability – general | arthritis | housing and homes | nutrition and healthy eating | workplace
  • Education Access & Quality
    • 4 Objectives
    • 12 Measures
    adolescents | children | people with disabilities | schools
  • Healthcare Access & Quality
    • 16 Objectives
    • 50 Measures
    healthcare access & quality – general | adolescents | cancer | children | community | drug & alcohol use | family planning | healthcare | health communication | health it | health insurance | oral conditions | people with disabilities | pregnancy & childbirth | sensory or communication disorders | sexually transmitted infections
  • Neighborhood & Built Environment
    • 12 Objectives
    • 29 Measures
    neighborhood & built environment – general | environmental health | health policy | housing & homes | injury prevention | people with disabilities | physical activity | respiratory disease | sensory or communication disorders | tobacco use | transportation | workplace
  • Social & Community Context
    • 8 Objectives
    • 23 Measures
    social and community context – general | adolescents | children | health Communication | health it | LGBT | nutrition and healthy eating | people with disabilities

Click to access social determinants of health key domain indicator sets

STEP 2: Infrastructure & Architecture

Roadmap with an arrow pointing to step 2.

Ensure existing infrastructure supports business & health information management needs.

Understand your business capabilities. Identify and address gaps.

Three categories 'Business Alignment', 'Health Information Management', and 'Technology Solutions'

Establish a set of data architecture rules, policies, standards, and models that govern the type of data collected and how it is to be used, stored, managed, and integrated within your organization and its database systems.

Optimize your data infrastructure and architecture to sustainably deliver readily available and accessible data to your user community.

Business capability map for Public Health
Sample of the business capability map for public health.

Download the Public Health Reference Architecture Guide

STEP 3: Data Engineering

Roadmap with an arrow pointing to step 3.

Get the right information to the right people at the right time.

Assemble the right team for your data integration development process.

Icon for Business Analyst.
Business Analyst

Communicates with business to identify requirements.

Icon for Data Architect.
Data Architect

Understands the data environment in a holistic manner and designs solutions.

Icon for Data Engineer.
Data Engineer

Creates data pipelines, big data platforms, and data integrations in databases, data warehouses, and data lakes, and works with various cloud and on-premises technologies to support business decisions.

Icon for Data Scientist.
Data Scientist

Represents business stakeholder(s) and programs. Develops, “trains,” and runs queries and algorithms for predictive analytics, machine learning, and data mining applications and creates visualizations for business stakeholders.
Icon of a funnel into a database.
Prepare your data for analytics and operational uses.

Icon of a gear with circuits.
Ensure interoperability by building data pipelines to integrate upstream and downstream data from multiple sources.

Icon of differently colored gears working together.
Integrate, cleanse, structure, and curate data for easy access and use in analytics applications.

STEP 4: Analytics & Reporting

Roadmap with an arrow pointing to step 4.

Formulate an enterprise reporting & analytics strategy.

Focus your enterprise reporting and analytics strategy on modeling the relationship between upstream social determinants of health and downstream outcomes.

Focus your enterprise reporting and analytics strategy on modeling the relationship between upstream social determinants of health and downstream outcomes for predictive and prescriptive decision making and place-based intervention.

Deliver actionable business insights by Nowcasting, Forecasting, and Scenario Modeling to accelerate data-driven decision making.

Develop Applied Artificial Intelligence (AAI) technologies as a service to make faster decisions and predict future outcomes.

Info-Tech Insight

AI is not a magic bullet. It is a tool for speeding up data-driven decision making. A more appropriate description of current AI technology is data-enabled, automated, adaptive decision support. Use when appropriate.

Build a robust & comprehensive data strategy


Sample of Info-Tech's 'Data & Analytics Landscape' data strategy.

Info-Tech’s reporting and analytics framework

Formulating an enterprise reporting ana analytics strategy requires the business vision and strategies to first be substantiated. Any optimization to the data warehouse, integration, and source layers is in turn driven by the enterprise reporting and analytics strategy.

Enterprise reporting and analytics strategy beginning with the input of 'Business vision / strategies' into 'Reporting & Analytics Strategy', which informs 'Data Warehouse/ Data Lake Strategy', which drives 'Data Integration Strategy', which informs 'Source Strategy (Content/Quality)'.

The current state of your integration and warehouse platforms determine what data can be used for BI and analytics.

Info-Tech’s AI framework

Business Goals

Automation • Integration • Scale • Intelligence • Insight

Arrow pointing down.
Analytical goals

Discover • Classify • Predict • Automate

Arrow pointing down.

Umbrella term 'Machine Learning (ML)' with its branches 'Computer Vision', 'Natural Language Processing (NLP)', and 'Robotic Process Automation (RPA)'.
Applied artificial intelligence (AAI) technologies are helping organizations make faster decisions and predict future outcomes.

What are social determinants of health? The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. (Source: US Department of Health & Human Services, ”Healthy People 2030”)

The Use of Social Determinants of
Health in Value-Based Care Delivery

Connect "upstream" determinants of health to "downstream" outcomes to make faster decisions and predict future outcomes today
89% of health occurs outside of the clinical space through our genetics, behavior, environment, and social circumstances. (Source: GoInvo, 2020)
Bridge visualization from upstream to downstream with steps 1 to 4 in between.

Emergent Public Health Practice

Upstream determinants are characterized by a social-environmental landscape & aligned with a value-based care orientation.

Health Equity Considerations

Social Inequities

Individual Level
  • Age
  • Class
  • Education
  • Gender/Gender Identity
  • Race/Ethnicity
  • Religion
  • Sexual Orientation

Systemic Inequities

Structural Level
  • Government & Agencies
  • Law & Regulations
  • Organizations, Corporations & Businesses
  • Schools
  • Urban/Regional Planning

Place-Based Conditions

Physical Environment
  • Environmental Land Use
  • Hazards Exposure
  • Housing & Zoning
  • Redlining
  • Residential Segregation
  • Transportation Access
Economic & Work Environment
  • Employment
  • Income
  • Occupational Hazards
  • Structural Barriers

Social Environment
  • Class, Gender, Ethnicity
  • Social Capital
  • Social Cohesion
  • Violence
Services Environment
  • Education Access & Quality
  • Healthcare Access & Quality
  • Social Services
Leverage and use leading-edge industry standards & resources for comparison measurement.

Example: Lean on Healthy People 2030 Social Determinants of Health Domains, Objectives & Measures

Benchmark using the objectives and measures in the five domains.

Ensure existing infrastructure supports business & health information management needs.

Establish a set of data architecture rules, policies, standards & models

Optimize your data infrastructure and architecture

Get the right information to the right people at the right time.

Assemble the right team for your data integration development process

Prepare your data for analytics and operational uses.

Ensure interoperability by building data pipelines to integrate upstream and downstream data from multiple sources.

Formulate an enterprise reporting & analytics strategy.

Develop applied artificial intelligence (AAI) technologies as a service

Nowcasting • Forecasting • Scenario Modeling

Deliver actionable business insights. Make faster decisions and predict future outcomes.

Current Public Health Practice

Downstream outcomes are characterized by a clinical landscape & aligned with a fee-for-service care orientation.

Health Risk Factors & Conditions

Disease & Injury

  • Alzheimer’s Disease & Other Dementias
  • Cancer
  • Communicable Disease
  • Chronic Disease
  • Chronic Lower Respiratory Disease
  • COVID-19
  • Diabetes
  • Diarrheal Diseases
  • Heart Disease
  • Influenza and Pneumonia
  • Injury (Intentional & Unintentional)
  • Kidney Disease
  • Neonatal Conditions
  • Stroke

Mortality

  • Infant Mortality
  • Maternal Mortality
  • Life Expectancy
  • Suicide

Risk Behaviors

  • Alcohol Use
  • Drug Use
  • Low Physical Activity
  • Poor Nutrition
  • Sexual Behavior
  • Tobacco Use
  • Violence

Info-Tech Insight

Current public health practice is focused on downstream outcomes. To improve public health service capacity and capability, shift focus upstream to drive primary prevention, core functions, and essential services. Leverage standard metrics for comparison. Use innovative technologies to predict future outcomes today through automated assessment and place-based intervention.

Leading SDOH Data Sources

  • HP 2030
  • WHO
  • CDC
  • ONC ISA
  • AHRQ
  • HL7 Gravity Project
Leverage leading-edge industry standards and resources to build interoperable SDOH data sets for comparison measurement and cost optimization.
Logo for Healthy People 2030.

Click to Access Data Sets

5 key SDOH domains, 45 objectives, 123 comparison measures, data sources, and methodology
Logo for Gravity Project.

Click to Access Data Sets

17 domains, master data lists, domain-specific data elements, metadata, and domain definitions
Logo for HealthIT.gov.

Click to Access ISA Code Sets

Interoperability standards advisory (ISA), SDOH vocabulary, code sets, and terminology
Logos for AHRQ, H-CUP, and MEPS.

Click to Access SDOH Database

Curated and linkable federal datasets and other publicly available data sources across domains
Logo for CDC.

Click to Access Data Sources

SDOH data sources and tools including chronic disease indicators, federal data, and vulnerable populations, among others
Logo for WHO.

Click to Access Data Sets

A gateway to global health datasets and access to over 1000 indicators on priority health topics including health equity
Return to Slide #7

Establish Baseline Metrics

Baseline metrics will be improved through:

  1. Leveraging and using leading-edge industry standards and resources for comparison measurement.
      Example: Lean on Healthy People 2030 SDOH domains, objectives, and measures.
  2. Benchmarking using the objectives and measures in the five domains – Education Access & Quality, Healthcare Access & Quality, Economic Stability, Social & Community Context, and Neighborhood & Built Environment.

Track Metrics

Track metrics throughout the project to assess and monitor population health status (Essential Public Health Service #1 – Assess and monitor population health status, factors that influence health, and community needs and assets. (CDC, Revised 2020)) and keep stakeholders informed.

Healthy People 2030 5 Key SDOH Domains
Legend of Key Domains: 'Education Access & Quality', 'Health Care Access & Quality', 'Economic Stability', 'Social & Community Context', 'Neighborhood & Built Environment'.
Publicly available data sources for SDOH data set development, integration, analytics, reporting, and Applied Artificial Intelligence (AAI).
Table of metrics for tracking key domains.
Healthy People 2030 features many highly specified objectives related to SDOH. These objectives or indicators, when mapped to "upstream" conditions and connected to "downstream" outcomes, highlight the importance of these factors – usually unrelated to healthcare delivery – in improving health and reducing health disparities. Use comparison data to track your progress toward value-based care strategic goals and against national trends. Connect “upstream" conditions to "downstream" outcomes for predictive analytics and primary prevention – nowcasting, forecasting, and scenario modeling.

Click to access social determinants of health key domain indicator sets

Info-Tech offers various levels of support to best suit your needs

DIY Toolkit

Guided Implementation

Workshop

Consulting

"Our team has already made this critical project a priority, and we have the time and capability, but some guidance along the way would be helpful." "Our team knows that we need to fix a process, but we need assistance to determine where to focus. Some check-ins along the way would help keep us on track." "We need to hit the ground running and get this project kicked off immediately. Our team has the ability to take this over once we get a framework and strategy in place." "Our team does not have the time or the knowledge to take this project on. We need assistance through the entirety of this project."

Diagnostics and consistent frameworks used throughout all four options

Our research provides our members with the tools they need to succeed in an increasingly complex industry landscape

Industry Insights & Best Practices Executive Peer Group Discussions Analyst and Advisory Services
Graphic of a laptop with analytics underlays.

Industry-specific methodologies
Business reference architectures
Digital trends: the future of your industry
Core technology research
Peer benchmarking reports

Graphic of a peer network.

Executive collaboration
Peer-to-peer knowledge sharing
High-impact discussion topics

Graphic of a variety of presentations.

Digital maturity assessment
Digital strategy
Business-IT alignment
Digital governance and execution
Peer benchmarking

Capitalize on your industry membership to support your organization’s value-based care transition

Industry Research Members have access to expert analysts, research, and tools.

Visualize the art of the possible

Evolve your transition business strategy

Execute with confidence

The future of your industry

Assess your business capability and readiness

Zero-in on business objectives and set transition goals

Build vision and business strategy

Select and prioritize initiatives

Build your business-aligned innovation roadmap

Govern and manage implementation and execution

Next Steps

If you would like additional support, have our analysts guide you through other phases as part of an Info-Tech Workshop.

Photo of Neal Rosenblatt. Contact your account representative for more information.
workshops@infotech.com 1-888-670-8889

To accelerate this project even further, engage your IT team in an Info-Tech workshop with an Info-Tech analyst team.

Info-Tech analysts will join you and your team at your location or welcome you to Info-Tech’s historic Toronto office to participate in an innovative onsite workshop.

Info-Tech Resources

The following are sample activities that will be conducted by Info-Tech analysts with your team:

Sample of level 1, 2 & 3 business capability maps.
Model level 1, 2 & 3 business capability maps.
Using the business capability map as an accelerator, Info-Tech analysts will work with relevant stakeholders to modify and validate the business capability map to suit your organization’s context.
Sample of the social determinants of health strategic framework.
Develop a social determinants of health strategic framework.
Info-Tech analysts will work with relevant stakeholders to review the various capability assessment maps and identify opportunities within your organization to develop a SDOH strategic framework.

Bibliography

“About Social Determinants of Health (SDOH).” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 10 Mar. 2021. Web.

“Achieving Health Equity by Addressing the Social Determinants of Health.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 29 Mar. 2022. Web.

Alderwick, Hugh, and Laura M. Gottlieb. “Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems.” Milbank Quarterly. Vol. 27, no. 2, June 2019. Web.

Bay Area Regional Health Inequities Initiative. 14 Apr. 2022. Web.

Bozic, Kevin and James Wright. "Value-Based Healthcare and Orthopaedic Surgery." Clinical Orthopaedics and Related Research. Vol. 470, no. 4, April 2012. pp. 1004–5. Web.

“California Department of Public Health.” Let’s Get Healthy California, 2016. Web.

“Celebrating 25 Years and Launching the Revised 10 Essential Public Health Services.” Public Health National Center for Innovation. Accessed 19 May 2022.

Choi, Edwin, and Juhan Sonin. “Determinants of Health – Health Is More Than Medical Care.” GoInvo.com, 14 Apr. 2020. Accessed 19 Apr. 2022.

“The Commission of Social Determinants of Health.” World Health Organization (WHO). Accessed 24 May 2022.

Comstock, Tom. “What Is the History of Value-Based Care?” Elation Health, 12 Jan. 2022. Accessed 24 May 2022.

Dahlgren, G., and Margaret Whitehead. Policies and Strategies to Promote Social Equity in Health. Institute for Futures Studies, 1991.

Danaher, A. “Reducing Disparities and Improving Population Health: The Role of a Vibrant Community Sector.” Wellesley Institute, 2011. Web.

Dieterle, Robert. “The Gravity Project: HITAC ISP TF Presentation.” HL7 Gravity Project, 8 Apr. 2021.

Donkin, A., et al. “Global Action on the Social Determinants of Health.” BMJ Global Health, Vol. 3, no. 1, Jan 2018.

Dunkerley, J. et al. “Canada Beyond 150: The Future of Well-Being.” Government of Canada, 2017. Web.

Frieden, T. R. “A Framework for Public Health Action: The Health Impact Pyramid.” American Journal of Public Health, Vol. 100, no. 4, 2010. pp. 590-595.

“The Global Digital Health Partnership. Background.” Office of the National Coordinator for Health IT, 3 Aug. 2022.

“The Global Health Observatory, Health Data.” World Health Organization (WHO). Web.

Bibliography

“The Global Health Observatory: Health Inequality Monitor Database.” World Health Organization (WHO). Web.

“The Global Health Observatory: Indicators Index.” World Health Organization (WHO). Web.

“Health Equity Assessment Toolkit.” World Health Organization (WHO). Web.

“Health in All Policies: Helsinki Statement. Framework for Country Action.” World Health Organization Press, 2014. Web.

“Health Inequities in the South-East Asia Region: Selected Country Case Studies.” WHO Regional Office for South-East Asia, 2009. Web.

“Health Profile for England: 2017. Chapter 6: Social Determinants of Health.” Gov.UK, July 2017. Web.

“Healthy People 2030 Framework.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed 24 May 2022.

“Healthy People 2030,” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed 14 April 2022.

“Healthy People Partners and SDOH.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Web.

Hillemeier M, Lynch J, Harper S, Casper M. “Data Set Directory of Social Determinants of Health at the Local Level.” Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2004. Accessed 17 May 2022.

“The History of Healthy People.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed 24 May 2022.

Hussein, Taz and Mariah Collins (2016). “The Community Cure for Health Care.” Stanford Social Innovation Review. Web.

“IHI Triple Aim Initiative.” Institute for Healthcare Improvement. Accessed 24 May 2022.

“Interoperability Standards Advisory.” Office of the National Coordinator for Health IT. Accessed 15 May 2022.

Islam, M. Mofizul. “Social Determinants of Health and Related Inequalities: Confusion and Implications.” Frontiers in Public Health, Vol. 7, no. 11, 8 Feb. 2019. Web.

“Johns Hopkins Team Outlines Ways to Integrate SDOH Data.” Johns Hopkins Medicine. Web.

Kimpen, Jan. "Here's How to Make 'Value-Based Healthcare' a Reality." World Economic Forum, 12 February 2019. Web.

Lousberg, Carrie. HL7 Gravity Project. Terminology Workstream Dashboard.” Web.

Nilsson, Kerstin et al. “Experiences From Implementing Value-Based Healthcare at a Swedish University Hospital - A Longitudinal Interview Study.” BMC Health Services Research, Vol. 17:169, 28 Feb. 2017. Web.

Bibliography

Norman, Amy. “An Overview of the Triple Aim: A Framework to Help Healthcare Systems Optimize Performance.” Verywell Health, Feb. 2020. Accessed 30 May 2022.

“An Overview of the IHI Triple Aim.” Institute for Healthcare Improvement. Retrieved 30 May 2022.

Porter, Michael and Elizabeth Olmsted Teisberg. Redefining Health Care. Harvard Business Review Press, 2006.

Porter, Michael. "What Is Value in Health Care?" The New England Journal of Medicine, Vol. 363, no. 26, Dec. 2010. pp 2477–81.

“SDOH Data and Analytics.” U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Web.

Shah, A. "Value-Based Healthcare: A Global Assessment." Medtronic: Value Based Healthcare, 12 May 2016.

Siwicki, Bill. “How Advanced Analytics Can Help Solve SDOH Problems.” Healthcare IT News, 17 May 2022. Accessed 22 May 2022.

---. “How NLP Can Help With At-Risk Patients, SDOH and Pop Health.” Healthcare IT News. Accessed 23 May 2022.

“Social Determinants of Health Database (Beta Version).” U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Dec. 2020. Web.

“Social Determinants of Health Literature Summaries.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Web.

“Social Determinants of Health.” Australian Institute of Health and Welfare (AIHW), 23 Jul 2020. Web.

“Social Determinants of Health.” Office of the National Coordinator for Health IT. Accessed 15 May 2022.

“Social Determinants of Health.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed 24 May 2022.

“Social Determinants of Health.” World Health Organization (WHO). Accessed 24 May 2022.

Solar, O. and Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva, World Health Organization Press, 2010.

“Sources for Data on Social Determinants of Health.“ U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 30 Sept. 2021. Web.

Steinmann, G, et al. "Expert Consensus on Moving Towards a Value-Based Healthcare System in the Netherlands: A Delphi Study." BMJ Open, Vol. 11, no. 4, April 2021.

---. "Redefining Value: A Discourse Analysis On Value-Based Health Care". BMC Health Services Research, Vol. 20, no. 1, September 2020.

Bibliography

Teisberg, Elizabeth, et al. "Defining and Implementing Value-Based Health Care: A Strategic Framework." Academic Medicine, Vol. 95, no. 5, May 2020. pp. 682-685.

“10 Essential Public Health Services.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Web.

“UPMC Center for Social Impact: Expanding the Traditional Definitions of Health Care.” UPMC Health Plan. Accessed 13 May 2022.

“Value-Based Care Is the Future of Healthcare.” Enlace Health. Accessed 24 May 2022.

“What Is Value-Based Healthcare?” NEJM Catalyst Innovations in Care Delivery, Jan. 2017. Web.

INFO~TECH RESEARCH GROUP

Social Determinants of Health – Leading Frameworks

Return to Slide #7

Leading frameworks to address social determinants of health

The United States, Canada, the UK, and Australia, among other countries, and the World Health Organization recognize the importance of addressing social determinants of health as part of improving overall health and well-being.

Logo for the World Health Organization.
  • World Health Organization (WHO)
Logos for the US Department of Health and Human Services and the CDC.
  • US Department of Health and Human Services
    • Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)
    • Office of Disease Prevention and Health Promotion (ODPHP), Healthy People 2030
Flags for the USA, Canada, the UK, and Australia.
  • Other Nations
    • USA
    • Canada
    • UK
    • Australia

Catalog of Leading SDOH Frameworks

SDOH Framework Resources

Frameworks to address social determinants of health

Several SDOH frameworks have been developed to help communities, health professionals, and others begin to better understand and address a variety of factors that affect health.

Leading SDOH Frameworks

Country Framework Description Go-To Link
WHO A Conceptual Framework for Action on the Social Determinants of Health The WHO Conceptual SDOH framework demonstrates how social, economic, and political factors such as income, education, occupation, gender, race, and ethnicity influence a person's socioeconomic position, which, in turn, plays a role in determining health outcomes. Go to This SDOH Framework
WHO Health in All Policies: Helsinki Statement. Framework for Country Action Developed by the World Health Organization to serve as a “starter kit” for applying Health in All Policies in decision-making and implementation at national and subnational levels. Go to This SDOH Framework
United States Healthy People 2030 Social Determinants of Health Framework This framework, developed by the US Department of Health and Human Services, Office of Disease Prevention and Health Promotions, offers five key domains including 45 objectives and 123 measures. Go to This SDOH Framework
United States Achieving Health Equity by Addressing the Social Determinants of Health This framework, developed by the US Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), provides a multisectoral and multilevel collaborative approach focusing on several determinants including built environment, community-clinical linkages, food and nutrition security, social connectedness, and tobacco-free policy. Go to This SDOH Framework
United States A Framework for Public Health Action: The Health Impact Pyramid A 5-tier pyramid providing a framework to improve public health. It describes the impact of different types of public health interventions addressing the impact of social determinants of health. Go to This SDOH Framework
United States BARHII Framework The Bay Area Regional Health Inequities Initiative (BARHII) Framework illustrates the connection between upstream social inequalities and downstream health outcomes. Go to This SDOH Framework
Canada The Danaher Framework This framework is part of a larger effort to reduce health disparities and improve population health through contributions from the community sector. Go to This SDOH Framework
Canada How Digital Media Impacts the Social Determinants of Health A proposed health-focused approach to digital media in Canada. Go to This SDOH Framework
UK & EU The Dahlgren-Whitehead Rainbow Model This model maps the relationship between the individual, their environment and health. Go to This SDOH Framework

INFO~TECH RESEARCH GROUP

Glossary of Social Determinants of Health Data Sources

Info-Tech Research Group Inc. is a global leader in providing IT research and advice. Info-Tech’s products and services combine actionable insight and relevant advice with ready-to-use tools and templates that cover the full spectrum of IT concerns.
© 1997-2022 Info-Tech Research Group Inc.

Glossary

An alphabetical listing of social determinants of health data sources

Data Source

Abbreviation

Supplier

Years Available

Periodicity

Mode of Collection

Description

Population Covered

A – C
Abortion Provider Census APC Guttmacher Institute 1973 and 2017 Periodic – Every 3 years Census: mail questionnaire Data on the number and geographic distribution of abortions and abortion providers, the types of facilities offering services, and other aspects of abortion availability. All facilities known (or suspected) to provide abortions in the United States
American Community Survey ACS Census 2005 to present Annual Sample Survey: internet questionnaire, with mail option Provides annual estimates of income, education, employment, health insurance coverage, and housing costs and conditions for residents of the United States. US population, including the population living in group quarters
American Housing Survey AHS HUD & Census 1973 to present; annually prior to 1983, biennially from 1985 forward Biennial Sample survey: in-person and telephone interviews Provides current information on a wide range of housing subjects, including the composition of the nation's housing inventory, vacancies, physical condition of housing units, characteristics of occupants, indicators of housing and neighborhood quality, mortgages and other housing costs, home values, and characteristics of recent movers. Residential housing units in the US
Air Quality System AQS EPA 1990 to present Annual Surveillance data: active data collection Repository of ambient air quality data collected from state, local, and tribal air pollution control agencies. AQS stores data from over 10,000 monitors, 5,000 of which are currently active. Air quality measures taken in the 50 states, the District of Columbia, Puerto Rico and the US Virgin Islands
Common Core of Data CCD ED/NCES 1986 to present Annual Census: abstraction of data from records Statistical database – non-fiscal and fiscal – of all public elementary and secondary schools and Local Education Agencies (LEAs). All public elementary and secondary schools in the United States

(Source: Healthy People 2030)

Glossary: An alphabetical listing of social determinants of health data sources

Data Source

Abbreviation

Supplier

Years Available

Periodicity

Mode of Collection

Description

Population Covered

A – C (Cont’d)
Current Population SurveyCPSCensus and DOL/BLS1945 to presentMonthly and annualMulti-stage sample survey: household-based, one person responding for all household membersProvides current estimates and trends in employment, unemployment, earnings, and other characteristics of the general labor force, the population, and various population subgroups.US civilian, noninstitutionalized population ages 16 years and older
Current Population Survey Annual Social and Economic SupplementCPS-ASECCensus and DOL/BLS1998 to presentAnnualMulti-stage sample survey: household-based, one person responding for all household membersSame as CPS plus provides information on work experience, income, noncash benefits, and migration of persons ages 15 years and older.US civilian, noninstitutionalized population ages 16 years and older
Current Population Survey Food Security SupplementCPS-FSSCensus and USDA/ERS1995 to presentAnnualMulti-stage sample survey: household-based, one person responding for all household membersInformation on food access and adequacy, food spending, and sources of food assistance for the US population.US civilian, noninstitutionalized population
D – F
Early Hearing Detection and Intervention Hearing Screening and Follow-up SurveyEHDI/HSFSCDC/NCBDDD2005 to presentAnnualSurveillance data: passive data collectionEarly hearing detection to identify infants with permanent hearing loss as early as possible.Infants born in the United States, the District of Columbia, the territories, and 3 freely associated states
G – I
Health Information National Trends SurveyHINTSNIH/NCI2003, 2005, 2007, 2011, 2012, 2013, 2014, 2017, 2018, 2019Biennial 2003-2007; Annual 2011-2014, 2017-2020Sample survey; since 2011, mailed, self-administered questionnaire.Cross-sectional survey of a nationally-representative sample; monitor changes in health communication access, use, and degree to which people are engaged in healthy behaviors.Noninstitutionalized adults ages 18 and older in the United States
Healthcare Effectiveness Data and Information SetHEDISNCQA2001 to presentAnnualAbstraction of administrative claims data or data from other recordsA tool used by more than 90 percent of US health plans to measure performance on important dimensions of care and service.Persons enrolled in health plans that report quality results using HEDIS
Individuals with Disabilities Education Act DataIDEA dataED/OSERS2004 to presentAnnualCensusInformation on programs for infants, toddlers, and their families and of programs serving children ages 3 through 21. Infants and toddlers who receive early-intervention services, and children with disabilities who receive special education and related service.Children and youth covered by Parts B and C of the Individuals with Disabilities Act


(Source: Healthy People 2030)

Glossary: An alphabetical listing of social determinants of health data sources

Data Source

Abbreviation

Supplier

Years Available

Periodicity

Mode of Collection

Description

Population Covered

J – O
Medical Expenditure Panel SurveyMEPSAHRQ2014PeriodicSample SurveyCollected information about receipt of preventive care services.US civilian non-institutionalized population
National Assessment of Educational Progress (a.k.a. The Nation’s Report Card)NAEPED/NCES1969 to presentBiennialSample survey and assessmentAssessment of what America's students know and can do in various subject areas.Public and private school students in grades 4, 8, and 12
National Health and Nutrition Examination SurveyNHANESCDC/NCHS1960-1994; 1999 to presentContinuous; data released in 2-year cyclesSample survey: in-home personal interviews, and physical examinations and laboratory tests in mobile examination centers (MEC)Assesses the health and nutritional status of adults and children in the United States.From 1988 to 1994 (NHANES III), the survey targeted the US civilian noninstitutionalized population aged 2 months and older. Since 1999, all ages are covered.
National Health Interview SurveyNHISCDC/NCHS1957 to presentAnnualSample survey: personal interviews in households using CAPI.Monitors the health of the civilian non-institutionalized US population through the collection and analysis of data on a broad range of health topics.US civilian noninstitutionalized population.
National HIV Surveillance SystemNHSSCDC/NCHHSTP1981 to presentAnnualSurveillance data: active data collectionSurveillance data on HIV infection and AIDSAll 50 states, the District of Columbia, and 6 US dependent areas
National Hospital Ambulatory Medical Care SurveyNHAMCSCDC/NCHS1992 – presentAnnualMulti-stage probability sample surveyData on the utilization and provision of medical care services provided in hospital emergency and outpatient departments. Data are collected from medical records.The survey is a representative sample of visits to emergency departments and outpatient departments of nonfederal, short-stay, or general hospitals. Telephone contacts are excluded.
National Survey of Children's HealthNSCHHRSA/MCHB2003, 2007, 2011/12, 2016, 2017, 2018AnnualSelf-administered web and paper-based questionnaires.Provides annual national and state-level information on the health and wellbeing of children ages 0-17 years in the United States.Children ages 0 through 17 years in the 50 states and the District of Columbia.
National Survey of Family GrowthNSFGCDC/NCHS1973-2002; 2006-2019Continuous since 2006Sample survey: in-person interviews, supplemented by audio computer-assisted self-administered interviews for more sensitive items.Information on pregnancy/birth histories, family formation (including marriage and cohabitation), infertility, use of contraception, and general and reproductive health.Since the 2002 survey, men and women ages 15 to 44 years in the household population of the United States, and since 2015, men and women ages 15-49 in this same population.
National Survey on Drug Use and HealthNSDUHSAMHSAPeriodically since 1971; Annually since 1990AnnualSample survey: in-person interviews plus audio computer-assisted self-administered interviews for sensitive items.Statistical information on the use of tobacco, alcohol, prescription psychotherapeutic drugs, and other substances. The survey also includes several series of questions focusing on mental health issues.US civilian noninstitutionalized population ages 12 years and older.


(Source: Healthy People 2030)

Glossary: An alphabetical listing of social determinants of health data sources

Data Source

Abbreviation

Supplier

Years Available

Periodicity

Mode of Collection

Description

Population Covered

J – O (Cont’d)
National Vital Statistics System - MortalityNVSS-MCDC/NCHS1900 to presentAnnualCensus: records of all deaths registered in the United StatesVital statistics mortality data on demographic, geographic, and cause-of-death information.The US population
National Vital Statistics System - NatalityNVSS-NCDC/NCHS1915 to present (Not all states participated prior to 1933)AnnualCensus: records of all births registered in the United StatesVital statistics natality data of demographic, geographic, and medical and health information on all births occurring in the United States.US population. All births registered within the United States
P – R
Population EstimatesN/ACensusSince 1790AnnualCensus enumeration and modeled adjustmentsPopulation estimatesAll US residents
Residential Information Systems Project – Annual Survey of State Developmental Disabilities AgenciesRISPUniversity of Minnesota1977 to presentAnnualAdministrative data submitted by State IDD agencies via online survey or a word document that mirrors the online surveyNational and state level longitudinal records of long-term supports and services (LTSS) for people with intellectual and developmental disabilities (IDD), including the history of institutionalization, deinstitutionalization, and the development of community-based LTSS.Medicaid and state-funded LTSS managed by, or under the auspices of, state IDD agencies
S – U
Safe Drinking Water Information SystemSDWISEPA/OW2013 to presentAnnualCensus: reports on all public water systemsDatabases that stores information about drinking water on 156,000 public water systems.Persons served by community water systems (CWS)
State Tobacco Activities Tracking and Evaluation SystemSTATECDC/NCCDPHP1996 to presentAnnualAbstraction of administrative /claims data or data from other recordsElectronic data warehouse containing up-to-date and historical state-level data on tobacco use prevention and control.US States
Superfund Enterprise Management SystemSEMSEPA2002 - presentAnnual or more oftenFederally required reporting to SEMSSuperfund program data on human exposure.Superfund National Priorities List (NPL) sites and sites with Superfund Alternative Approach (SAA) agreements
Survey of Occupational Injuries and IllnessesSOIIDOL/BLS1971 to presentAnnualMandatory reports of occupational injuries, and illnesses by a sample of employersFederal/state program that collects statistics used to identify problems with workplace safety and to develop programs to improve workplace safety.Mandatory reports of occupational injuries, and illnesses by a sample of employers. Excludes the self-employed, farms with fewer than 11 employees, private households, and federal government agencies.


(Source: Healthy People 2030)

Glossary: An alphabetical listing of social determinants of health data sources

Data Source

Abbreviation

Supplier

Years Available

Periodicity

Mode of Collection

Description

Population Covered

S – U (Cont’d)
Tobacco Use Supplement to the Current Population SurveyTUS-CPSCensus, DOL/BSL, NIH/NCI, FDA/CTP1992-1993, 1995-1996, 1998-1999, 2000, 2001-2002, 2003, 2006-2007, 2010-2011, 2014-2015, 2018-2019PeriodicSample Survey: self-responses and proxy responsesSource of national, state, and sub-state data on tobacco use behavior, attitudes, and policies in the United States.Civilian, non-institutionalized population ages 18 years and older (data for the 1992 to 2006 TUS-CPS are for persons ages 15 years and older)
Toxics Release InventoryTRIEPA1987 to presentAnnualSurveillance data: passive data collectionData on the quantities of chemicals included on the TRI list of toxic chemicals that are released into the environment or otherwise managed as waste by certain industrial and federal facilities. Also provides data on pollution prevention activities reported by these facilities.Industrial and Federal facilities
Uniform Crime Reporting SystemUCRDOJ/FBISince 1960PassiveSurveillance dataNational and State crime estimates of more than 18,000 law enforcement agencies voluntarily reporting data on crimes brought to their attention. Eight major classifications of crime, known as the crime index, are tracked to gauge fluctuations in the overall volume and rate of crime.Nation and State crime estimates
V – Z
Water Fluoridation Reporting SystemWFRSCDC/NCCDPHP1998 to presentAnnualCensus: reports on the fluoridation status of all community water systemsOnline tool that helps states manage the quality of their water fluoridation programs. WFRS information is also the basis for national reports that describe the percentage of the US population who receive fluoridated drinking water through community water systems.Community water systems in the United States


(Source: Healthy People 2030)

INFO~TECH RESEARCH GROUP

Social Determinants of Health Key Domain Data Indicators and Measures

Info-Tech Research Group Inc. is a global leader in providing IT research and advice. Info-Tech’s products and services combine actionable insight and relevant advice with ready-to-use tools and templates that cover the full spectrum of IT concerns.
© 1997-2022 Info-Tech Research Group Inc.

Return to Slide #12

Return to Slide #18

Social determinants of health indicator sets

Leverage Healthy People 2030 key domains and objectives for standardization and comparison measurement

Info-Tech Insight

Curate SDOH data indicators for prediction modeling:

  1. Map SDOH indicators to "upstream" determinants.
  2. Connect "upstream" determinants to "downstream" health outcomes.
  3. Train/test models for nowcasting, forecasting, and scenario modeling.
SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
Healthcare Access & Quality
INDICATOR: Healthcare Access & Quality – General
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults who get recommended evidence-based preventive healthcare – AHS‑08 10.9% 8.0% 8.0% MEPS Physical Environment | Services Environment | Economic & Work Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Reduce the proportion of emergency department visits with a longer wait time than recommended – AHS‑09 12.0% 19.2% 19.2% NHAMCS, CDC/NCHS Economic & Work Environment | Social Environment | Services Environment
INDICATOR: Adolescents
MEASURE: Increase the proportion of adolescents who had a preventive healthcare visit in the past year – AH‑01 82.6% 78.7% 78.7% NSCH, HRSA/MCHB Transportation Access | Economic & Work Environment | Services Environment
MEASURE: Increase the proportion of adolescents who speak privately with a provider at a preventive medical visit – AH‑02 43.3% 38.4% 38.4% NSCH, HRSA/MCHB Transportation Access | Economic & Work Environment | Services Environment | Structural
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Cancer
MEASURE: Increase the proportion of adults who get screened for lung cancer – C‑03 7.5% 4.5% 4.5% NHIS, CDC/NCHS Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
MEASURE: Increase the proportion of females who get screened for breast cancer – C‑05 77.1% 72.8% 72.8% NHIS, CDC/NCHS Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults who get screened for colorectal cancer – C‑07 74.4% 65.2% 65.2% NHIS, CDC/NCHS Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
MEASURE: Increase the proportion of females who get screened for cervical cancer – C‑09 84.3% 80.5% 80.5% NHIS, CDC/NCHS Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people who discuss interventions to prevent cancer with their providers – C‑R02 NO DATA NO DATA NO DATA Status: Research Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
MEASURE: Increase the proportion of people with colorectal cancer who get tested for Lynch syndrome – C‑R03 NO DATA NO DATA NO DATA Status: Research Physical Environment | Services Environment | Economic & Work Environment | Social Inequities
INDICATOR: Children
MEASURE: Increase the proportion of children with developmental delays who get intervention services by age 4 years – EMC‑R01 NO DATA NO DATA NO DATA Status: Research Physical Environment | Services Environment | Economic & Work Environment | Social Environment
INDICATOR: Community
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the number of community organizations that provide prevention services – ECBP‑D07 NO DATA NO DATA NO DATA Status: Developmental Social Environment | Services Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Drug and Alcohol Use
MEASURE: Increase the proportion of people with a substance use disorder who got treatment in the past year – SU‑01 14.0% 11.1% 11.1% NSDUH, SAMHSA Services Environment | Social Environment
INDICATOR: Family Planning
MEASURE: Increase the proportion of women who get needed publicly funded birth control services and support – FP‑09 47.9% 42.9% 42.9% NSFG, CDC/NCHS; APC, Guttmacher Institute; ACS, Census Services Environment | Social Environment | Systemic Inequities | Transportation Access
INDICATOR: Healthcare
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Reduce the proportion of people who can't get medical care when they need it – AHS‑04 3.3% 4.1% 4.1% MEPS, AHRQ Services Environment | Physical Environment | Economic & Work Environment | Systemic Inequities
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Reduce the proportion of people who can't get prescription medicines when they need them – AHS‑06 3.0% 3.4% 3.4% MEPS, AHRQ Services Environment | Physical Environment | Economic & Work Environment | Systemic Inequities
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people with a usual primary care provider – AHS‑07 84.0% 76.0% 76.0% MEPS, AHRQ Services Environment | Physical Environment | Economic & Work Environment | Systemic Inequities
MEASURE: Increase use of the oral healthcare system – OH‑08 45.0% 43.3% 43.3% MEPS, AHRQ Services Environment | Physical Environment | Economic & Work Environment | Systemic Inequities
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the ability of primary care and behavioral health professionals to provide more high-quality care to patients who need it – AHS‑R01 NO DATA NO DATA NO DATA Status: Research Services Environment | Physical Environment | Economic & Work Environment | Systemic Inequities
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Health Communication
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults whose healthcare provider checked their understanding – HC/HIT‑01 32.2% 26.6% 26.6% MEPS, AHRQ Services Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Decrease the proportion of adults who report poor communication with their healthcare provider – HC/HIT‑02 8.0% 8.9% 8.9% MEPS, AHRQ Services Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults whose healthcare providers involved them in decisions as much as they wanted – HC/HIT‑03 62.7% 52.8% 52.8% HINTS, NIH/NCI Services Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults with limited English proficiency who say their providers explain things clearly – HC/HIT‑D11 NO DATA NO DATA NO DATA Status: Developmental Services Environment
INDICATOR: Health IT
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults offered online access to their medical record – HC/HIT‑06 63.0% 53.2% 53.2% HINTS, NIH/NCI Services Environment | Economic & Work Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of hospitals that exchange and use outside electronic health information – HC/HIT‑D05 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Systemic Inequities – Structural Level
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of hospitals with access to necessary electronic information – HC/HIT‑D06 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Systemic Inequities – Structural Level
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of doctors with electronic access to information they need – HC/HIT‑D07 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Systemic Inequities – Structural Level
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of doctors who exchange and use outside electronic health information – HC/HIT‑D08 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Systemic Inequities – Structural Level
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Health IT (Cont’d)
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people who can view, download, and send their electronic health information – HC/HIT‑D09 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Economic & Work Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people who say their online medical record is easy to understand – HC/HIT‑D10 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Economic & Work Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the use of telehealth to improve access to health services – AHS‑R02 NO DATA NO DATA NO DATA Status: Research Services Environment | Economic & Work Environment | Systemic
INDICATOR: Health Insurance
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people with health insurance – AHS‑01 92.1% 89.0% 89.0% NHIS, CDC/NCHS Services Environment | Economic & Work Environment | Systemic
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people with prescription drug insurance – AHS‑03 70.6% 61.1% 61.1% NHIS, CDC/NCHS Services Environment | Economic & Work Environment | Systemic
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Reduce the proportion of people under 65 years who are underinsured – AHS‑R03 NO DATA NO DATA NO DATA Status: Research Services Environment | Economic & Work Environment | Systemic
INDICATOR: Oral Conditions
MEASURE: Increase the proportion of people with dental insurance – AHS‑02 59.8% 54.4% 54.4% NHIS, CDC/NCHS Services Environment | Economic & Work Environment | Systemic
MEASURE: Reduce the proportion of people who can't get the dental care they need when they need it – AHS‑05 4.1% 4.6% 4.6% MEPS, AHRQ Services Environment | Economic & Work Environment | Systemic | Physical Environment
MEASURE: Increase the proportion of low-income youth who have a preventive dental visit – OH‑09 82.7% 78.8% 78.8% NSCH, HRSA/MCHB Services Environment | Economic & Work Environment | Systemic | Physical Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: People with Disabilities
MEASURE: Increase the proportion of adults with traumatic brain injury who can do at least half of preinjury activities 5 years after rehabilitation – DH‑D02 NO DATA NO DATA NO DATA Status: Developmental Services Environment | Social Environment
INDICATOR: Pregnancy & Childbirth
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of pregnant women who receive early and adequate prenatal care – MICH‑08 80.5% 76.7% 76.4% NVSS-N, CDC/NCHS Services Environment | Transportation | Systemic | Social Environment
INDICATOR: Sensory or Communication Disorders
MEASURE: Increase the proportion of infants who didn’t pass their hearing screening who get evaluated for hearing loss by age 3 months – HOSCD‑02 79.2% 77.0% 75.0% EHDI/HSFS, CDC/NCBDDD Services Environment | Transportation | Employment | Income | Systemic | Social Environment
MEASURE: Increase the proportion of infants with hearing loss who get intervention services by age 6 months – HOSCD‑03 62.9% 55.0% 53.0% EHDI/HSFS, CDC/NCBDDD Services Environment | Transportation | Employment | Income | Systemic | Social Environment
MEASURE: Increase the proportion of newborns who get screened for hearing loss by age 1 month – HOSCD‑01 97.0% 95.0% 95.0% EHDI/HSFS, CDC/NCBDDD Services Environment | Transportation | Employment | Income | Systemic | Social Environment
MEASURE: Increase access to vision services in community health centers – V‑R01 NO DATA NO DATA NO DATA Status: Research Services Environment | Transportation | Employment | Income | Systemic | Social Environment
INDICATOR: Sexually Transmitted Infections
MEASURE: Increase the proportion of sexually active female adolescents and young women who get screened for chlamydia – STI‑01 76.5% 76.5% 54.4% HEDIS, NCQA Services Environment | Transportation | Systemic | Social Inequities | Social Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Sexually Transmitted Infections (Cont’d)
MEASURE: Reduce the number of new HIV infections – HIV‑01 3,000 persons 37,000 persons 37,000 persons NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
MEASURE: Increase knowledge of HIV status – HIV‑02 95.0% 85.8% 85.8% NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
MEASURE: Reduce the number of new HIV diagnoses – HIV‑03 3,835 persons 38,351 persons 38,351 persons NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
MEASURE: Increase linkage to HIV medical care – HIV‑04 95.0% 77.8% 77.8% NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
MEASURE: Increase viral suppression – HIV‑05 95.0% 63.1% 63.1% NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
MEASURE: Reduce the rate of mother-to-child HIV transmission – HIV‑06 0.9 per 100,000 1.3 per 100,000 1.3 per 100,000 NHSS, CDC/NCHHSTP Services Environment | Social Environment | Social & Systemic
Economic Stability
INDICATOR: Economic Stability – General
MEASURE: Reduce the proportion of adolescents and young adults who aren't in school or working – AH‑09 10.1% 11.2% 11.2% CPS, Census and DOL/BLS Systemic – Structural | Services Environment | Social Environment
MEASURE: Reduce the proportion of people living in poverty – SDOH‑01 8.0% 11.8% 11.8% CPS-ASEC, Census and DOL/BLS Systemic | Physical Environment | Economic & Work Environment
MEASURE: Increase employment in working-age people – SDOH‑02 75.0% 70.6% 70.6% CPS-ASEC, Census and DOL/BLS Systemic Inequities | Economic & Work Environment | Social Capital / Cohesion
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Economic Stability – General (Cont’d)
MEASURE: Increase the proportion of children living with at least 1 parent who works full time – SDOH‑03 85.1% 77.9% 77.9% CPS-ASEC, Census and DOL/BLS Economic & Work Environment | Social Environment
INDICATOR: Arthritis
MEASURE: Reduce the proportion of adults with arthritis whose arthritis limits their work – A‑03 29.5% 33.0% 33.0% NHIS, CDC/NCHS Economic & Work Environment | Services Environment
INDICATOR: Housing and Homes
MEASURE: Reduce the proportion of families that spend more than 30 percent of income on housing – SDOH‑04 25.5% 34.6% 34.6% AHS, HUD & Census Economic & Work Environment | Systemic | Physical Environment
INDICATOR: Nutrition and Healthy Eating
MEASURE: Reduce household food insecurity and hunger – NWS‑01 6.0% 11.1% 11.1% CPS-FSS, Census and USDA/ERS Economic & Work Environment | Systemic | Physical Environment
MEASURE: Eliminate very low food security in children – NWS‑02 0.0% 0.59% 0.59% CPS-FSS, Census and USDA/ERS Economic & Work Environment | Systemic | Physical Environment
INDICATOR: Workplace
MEASURE: Reduce work-related injuries resulting in missed workdays – OSH‑02 63.8 per 10,000 86.9 per 10,000 89.4 per 10,000 SOII, DOL/BLS Economic & Work Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
Social and Community Context
INDICATOR: Social and Community Context – General
MEASURE: Reduce anxiety and depression in family caregivers of people with disabilities – DH‑D01 NO DATA NO DATA NO DATA Status: Developmental Social Environment | Services Environment
MEASURE: Reduce the proportion of children with a parent or guardian who has served time in jail – SDOH‑05 5.2% 7.5% 7.7% NSCH, HRSA/MCHB Social Environment | Systemic Inequities | Economic & Work Environment
INDICATOR: Adolescents
MEASURE: Increase the proportion of adolescents who have an adult they can talk to about serious problems – AH‑03 82.9% 79.0% 79.0% NSDUH, SAMHSA Social Environment | Services Environment
MEASURE: Increase the proportion of adolescents in foster care who show signs of being ready for adulthood – AH‑R02 NO DATA NO DATA NO DATA Status: Research Social Environment | Services Environment | Systemic Environment – Schools
INDICATOR: Children
MEASURE: Increase the proportion of children and adolescents who communicate positively with their parents – EMC‑01 73.0% 65.3% 68.5% NSCH, HRSA/MCHB Social Environment | Systemic Inequities – Schools
MEASURE: Increase the proportion of children whose parents read to them at least 4 days per week – EMC‑02 63.2% 55.0% 58.3% NSCH, HRSA/MCHB Social Environment – Social Cohesion
MEASURE: Increase the proportion of children and adolescents who show resilience to challenges and stress – EMC‑D07 NO DATA NO DATA NO DATA Status: Developmental Social Environment | Services Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Health Communication
MEASURE: Increase the proportion of adults who talk to friends or family about their health – HC/HIT‑04 92.3% 86.9% 86.9% HINTS, NIH/NCI Social Environment | Economic & Work Environment
MEASURE: Increase the health literacy of the population – HC/HIT‑R01 NO DATA NO DATA NO DATA Status: Research Services Environment | Systemic | Economic & Work Environment
INDICATOR: Health IT
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of adults who use IT to track healthcare data or communicate with providers – HC/HIT‑07 87.3% 80.0% 80.0% HINTS, NIH/NCI Economic & Work Environment | Services Environment
INDICATOR: LGBT
MEASURE: Reduce bullying of transgender students – LGBT‑D01 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities | Social Inequities | Social Environment
INDICATOR: Nutrition and Healthy Eating
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Eliminate very low food security in children – NWS‑02 0.0% 0.59% 0.59% CPS-FSS, Census and USDA/ERS Systemic Inequities | Economic & Work Environment | Physical Environment
INDICATOR: People with Disabilities
MEASURE: Reduce the proportion of people with intellectual and developmental disabilities who live in institutional settings with 7 or more people – DH‑03 11.5% 21.5% 22.7% RISP, University of Minnesota Systemic Inequities | Physical Environment | Services Environment | Social Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
Neighborhood and Built Environment
INDICATOR: Neighborhood and Built Environment – General
MEASURE: Reduce the rate of minors and young adults committing violent crimes – AH‑10 199.2 per 100,000 249.0 per 100,000 249.0 per 100,000 UCR, DOJ/FBI Social Environment | Systemic | Social Inequities | Physical Environment
MEASURE: Increase the proportion of adults with broadband internet – HC/HIT‑05 60.8% 55.9% 55.9% HINTS, NIH/NCI Economic & Work Environment | Systemic | Social Environment
MEASURE: Increase the proportion of schools with policies and practices that promote health and safety – EH‑D01 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities – Structural Level
INDICATOR: Environmental Health
MEASURE: Increase the proportion of people whose water supply meets Safe Drinking Water Act regulations – EH‑03 92.1% 93.0% 90.2% SDWIS, EPA/OW Physical Environment | Systemic Inequities
MEASURE: Reduce the amount of toxic pollutants released into the environment – EH‑06 1,862,612 tons 1,690,240 tons 1,970,088 tons TRI, EPA Physical Environment | Systemic Inequities
MEASURE: Reduce the number of days people are exposed to unhealthy air – EH‑01 3.9B AQI-Wt. people days 4.3B AQI-Wt. people days 4.3B AQI-Wt. people days AQS, EPA Physical Environment | Systemic Inequities
MEASURE: Reduce health and environmental risks from hazardous sites – EH‑05 87.3% 83.8% 83.8% SEMS, EPA Physical Environment | Systemic Inequities | Economic & Work Environment
INDICATOR: Health Policy
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of people whose water systems have the recommended amount of fluoride – OH‑11 77.1% 72.8% 72.8% WFRS, CDC/NCCDPHP Physical Environment | Systemic Inequities
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Housing and Homes
MEASURE: Reduce blood lead levels in children aged 1 to 5 years – EH‑04 1.18 µg/dL 3.31 µg/dL 3.31 µg/dL NHANES, CDC/NCHS Physical Environment | Systemic Inequities
MEASURE: Reduce the proportion of families that spend more than 30 percent of income on housing – SDOH‑04 25.5% 34.6% 34.6% AHS, HUD & Census Economic & Work Environment | Physical Environment
INDICATOR: Injury Prevention
MEASURE: Reduce deaths from motor vehicle crashes – IVP‑06 10.1 per 100,000 11.1 per 100,000 11.2 per 100,000 NVSS-M, CDC/NCHS; Population Estimates, Census Physical Environment | Systemic Inequities
INDICATOR: People with Disabilities
MEASURE: Increase the proportion of homes that have an entrance without steps – DH‑04 53.1% 53.6% 51.3% AHS, HUD & Census Physical Environment
INDICATOR: Physical Activity
MEASURE: Increase the proportion of adults who walk or bike to get places – PA‑10 26.8% 22.5% 22.5% NHANES, CDC/NCHS Physical Environment | Systemic Inequities
MEASURE: Increase the proportion of adolescents who walk or bike to get places – PA‑11 44.9% 39.8% 39.8% NHANES, CDC/NCHS Physical Environment | Systemic Inequities
INDICATOR: Respiratory Disease
MEASURE: Reduce asthma deaths – RD‑01 8.9 per 100,000 9.7 per 100,000 9.4 per 100,000 NVSS-M, CDC/NCHS; Population Estimates, Census Physical Environment | Systemic | Services Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Respiratory Disease (Cont’d)
MEASURE: Reduce emergency department visits for children under 5 years with asthma – RD‑02 65.7 per 10,000 129.6 per 10,000 129.6 per 10,000 NHAMCS, CDC/NCHS; Population Estimates, Census Physical Environment | Systemic | Services Environment
MEASURE: Reduce emergency department visits for people aged 5 years and over with asthma – RD‑03 44.0 per 10,000 54.9 per 10,000 54.9 per 10,000 NHAMCS, CDC/NCHS; Population Estimates, Census Physical Environment | Systemic | Services Environment
MEASURE: Reduce asthma attacks – RD‑04 38.1% 45.2% 45.2% NHIS, CDC/NCHS Physical Environment | Systemic | Services Environment
MEASURE: Reduce hospitalizations for asthma in children under 5 years – RD‑D01 NO DATA NO DATA NO DATA Status: Developmental Physical Environment | Systemic | Services Environment
MEASURE: Reduce hospitalizations for asthma in people aged 5 to 64 years – RD‑D02 NO DATA NO DATA NO DATA Status: Developmental Physical Environment | Systemic | Services Environment
MEASURE: Reduce hospitalizations for asthma in adults aged 65 years and over – RD‑D03 NO DATA NO DATA NO DATA Status: Developmental Physical Environment | Systemic | Services Environment
MEASURE: Reduce hospitalizations for COPD – RD‑D04 NO DATA NO DATA NO DATA Status: Developmental Physical Environment | Systemic | Services Environment
INDICATOR: Sensory or Communication Disorders
MEASURE: Reduce the proportion of adults who have hearing loss due to noise exposure – HOSCD‑09 79.0 per 1,000 97.8 per 1,000 97.8 per 1,000 NHANES, CDC/NCHS Physical Environment | Systemic Inequities
INDICATOR: Tobacco Use
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the number of states, territories, and DC that prohibit smoking in worksites, restaurants, and bars – TU‑17 58 States 32 States 32 States STATE, CDC/NCCDPHP Systemic Inequities | Economic & Work Environment | Social Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Tobacco Use (Cont’d)
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of smoke-free homes – TU‑18 92.9% 86.5% 86.5% TUS-CPS, Census, DOL/BSL, NIH/NCI, FDA/CTP Social Environment
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Reduce the proportion of people who don't smoke but are exposed to secondhand smoke – TU‑19 17.3% 25.5% 25.5% NHANES, CDC/NCHS Systemic Inequities | Economic & Work Environment | Social Environment
MEASURE: Increase the number of states, territories, and DC that prohibit smoking in multiunit housing – TU‑R01 NO DATA NO DATA NO DATA Status: Research Systemic Inequities | Social Environment
INDICATOR: Transportation
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase trips to work made by mass transit – EH‑02 5.3% 5.0% 5.0% ACS, Census Systemic Inequities – Urban / Regional Planning | Physical Environment
INDICATOR: Workplace
Icon for 'Value-Based Care Alignment/Cost Optimization Business Opportunity'. MEASURE: Increase the proportion of worksites with policies that ban indoor smoking – ECBP‑D06 NO DATA NO DATA NO DATA Status: Developmental Economic & Work Environment | Systemic Inequities
Education Access & Quality
INDICATOR: Adolescents
MEASURE: Increase the proportion of high school students who graduate in 4 years – AH‑08 90.7% 85.8% 84.1% CCD, ED/NCES Systemic Inequities | Social Environment | Services Environment
MEASURE: Increase the proportion of high school graduates in college the October after graduating – SDOH‑06 73.7% 69.1% 69.1% CPS, Census and DOL/BLS Systemic Inequities | Social Environment | Services Environment | Economic & Work Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Adolescents (Cont’d)
MEASURE: Increase the proportion of 8th-graders with reading skills at or above the proficient level – AH‑R04 NO DATA NO DATA NO DATA Status: Research Systemic Inequities | Social Environment | Services Environment
MEASURE: Increase the proportion of 8th-graders with math skills at or above the proficient level – AH‑R05 NO DATA NO DATA NO DATA Status: Research Systemic Inequities | Social Environment | Services Environment
INDICATOR: Children
MEASURE: Increase the proportion of children who are developmentally ready for school – EMC‑D01 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities | Social Environment | Services Environment
MEASURE: Increase the proportion of children who participate in high-quality early childhood education programs – EMC‑D03 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities | Social Environment | Services Environment | Physical Environment
MEASURE: Increase the proportion of children and adolescents who get preventive mental healthcare in school – EMC‑D06 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities | Social Environment | Services Environment | Physical Environment
MEASURE: Increase the proportion of children with developmental delays who get intervention services by age 4 years – EMC‑R01 NO DATA NO DATA NO DATA Status: Research Systemic Inequities | Social Environment | Services Environment | Physical Environment
INDICATOR: People with Disabilities
MEASURE: Increase the proportion of students with disabilities who are usually in regular education programs – DH‑05 73.3% 63.5% 63.5% IDEA data, ED/OSERS Systemic Inequities | Social Environment | Services Environment | Physical Environment
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Social determinants of health data indicators and measures

SDOH INDICATOR HP 2030 KEY DOMAINS DATA STATUS DATA SOURCE(S)
(See Glossary of Data Sources)
ITRG SDOH
THOUGHT MODEL

"Upstream" Conditions
Icon for Key Domain 'Education Access & Quality'. Icon for Key Domain 'Healthcare Access & Quality'. Icon for Key Domain 'Economic Stability'. Icon for Key Domain 'Social & Community Context'. Icon for Key Domain 'Neighborhood & Built Environment'. TARGET MOST RECENT BASELINE DIRECTION
↑Increase
↓Decrease
INDICATOR: Schools
MEASURE: Increase the proportion of 4th-graders with reading skills at or above the proficient level – AH‑05 41.5% 36.6% 36.6% NAEP, ED/NCES Systemic Inequities | Social Environment | Services Environment | Physical Environment
MEASURE: Increase the proportion of 4th-graders with math skills at or above the proficient level – AH‑06 43.1% 40.2% 40.2% NAEP, ED/NCES Systemic Inequities | Social Environment | Services Environment | Physical Environment
MEASURE: Increase interprofessional prevention education in health professions training programs – ECBP‑D08 NO DATA NO DATA NO DATA Status: Developmental Systemic Inequities | Services Environment
End of Value Set
Legend for the 'Key Domains' icons.
Icon of a head with a lightbulb inside. Value-Based Care Alignment/Cost Optimization Business Opportunity
Source: Healthy People 2030

Info-Tech Insight

As an illustrative example, this table assembles an at-a-glance collection of highly specified SDOH indicators available from the US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Healthy People 2030. The Info-Tech Research Group has added a column connecting "upstream" conditions identified in the Thought Model presented on Slide 16 to each Healthy People 2030 SDOH indicator and measure as an example of how to apply the ITRG SDOH Thought Model as a strategic approach to analytics, reporting, and automated assessment 24/7/365. As a next step, ITRG recommends 1) connecting "upstream" conditions to "downstream" outcomes, leveraging leading-edge resources identified on Slide 7 – Leading SDOH Frameworks and Slide 17 – Leading SDOH Data Sources; and 2) following the four-step process introduced in this document and detailed in Slides 11-16 toward developing predictive analytics – nowcasting, forecasting, and scenario modeling – and primary prevention automated AI processes. Available levels of ITRG support – analyst calls, workshops, concierge, and consulting services – are indicated in Slides 19 – 22.

About Info-Tech

Info-Tech Research Group is the world’s fastest-growing information technology research and advisory company, proudly serving over 30,000 IT professionals.

We produce unbiased and highly relevant research to help CIOs and IT leaders make strategic, timely, and well-informed decisions. We partner closely with IT teams to provide everything they need, from actionable tools to analyst guidance, ensuring they deliver measurable results for their organizations.

What Is a Blueprint?

A blueprint is designed to be a roadmap, containing a methodology and the tools and templates you need to solve your IT problems.

Each blueprint can be accompanied by a Guided Implementation that provides you access to our world-class analysts to help you get through the project.

Talk to an Analyst

Our analyst calls are focused on helping our members use the research we produce, and our experts will guide you to successful project completion.

Book an Analyst Call on This Topic

You can start as early as tomorrow morning. Our analysts will explain the process during your first call.

Get Advice From a Subject Matter Expert

Each call will focus on explaining the material and helping you to plan your project, interpret and analyze the results of each project step, and set the direction for your next project step.

Unlock Sample Research

Author

Neal Rosenblatt

Visit our IT Cost Optimization Center
Over 100 analysts waiting to take your call right now: 1-519-432-3550 x2019