A prime example of how health systems can effectively address social determinants of health in the context on managing the health of populations is the Vermont Blueprint for Health. a This state-government program was created as a way to improve outcomes and control costs for patients with chronic conditions. The program integrates health care with social services by helping patient-centered medical homes collaborate with community health teams (CHTs) comprising nurse coordinators, social workers, dietitians, and others. A September 2015 study reporting on the initiative’s performance found that the medical homes supported by CHTs spent $482 less per patient over two years compared with practices that didn’t use CHTs. b The savings were a result of fewer hospitalizations because the social services the patients received reduced their need for medical care.
Karen Handmaker, MPP, is global leader, population health strategy, IBM Watson Health, Louisville, Ky.
a. Department of Vermont Health Access, Vermont Blueprint for Health, 2017.
b. Jones, C.Finison, K.McGraves-Lloyd, K.Tremblay, T.Mohlman, M.K.Tanzman, B.Hazard, MMaier, S., and Samuelson, Vermont’s Community-Oriented All-Payer Medical Home Model Reduces Expenditures and Utilization While Delivering High-Quality Care,” Population Health Management, June 2016.