Social Determinants of Health

Iowa’s SIM project proposes implementation of a core substructure that will expand the capacity for providers, health systems, public health agencies, statewide organizations, and communities to collectively promote interventions being piloted by the Community Care teams and other stakeholders that will minimize the impact of the social determinants on health (SDH).

In the post SIM environment, payers, providers, communities and government agencies recognize that “healthcare” is inclusive of the broader definition of health; considerations of healthcare will include supporting services and activities that focus on keeping people well, lowering healthcare risk, and the prevalence of chronic disease more than responding to unmanaged crisis.

Iowa’s investment in a standardized health risk assessment (HRA) tool to identify and influence SDH, will support providers in analyzing and acting on the individual and aggregated data collected.  The state will identify additional social needs questions to be added to the tool.

Three Ways SIM Will Address SDH

  • The development and/or enhancement of referral networks, in C3 regions, that address social needs for individuals having or at risk of having diabetes. Technical assistance will be provided to the C3s so the referral systems that are implemented are effective and efficient.
  • SDH interventions will be implemented in the Iowa SIM project through expanding the use of the Assess My Health (AMH) HRA expansion to additional payers or to the general population is also being explored.
  • The aggregated SDH data collected from the AMH completion will be shared with stakeholders to inform decision makers about the SDH needs across Iowa.
SIM partners have chosen the following definition of SDH from the Centers for Disease Control and Prevention (CDC) along with the five key areas identified in Healthy People 2020.
Social determinants are the complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.

Healthy People 2020’s five key areas of SDH:

  • Economic Stability
  • Education
  • Social and Community Context
  • Health and Health Care
  • Neighborhood and Built Environment

Information Resources

Public Meeting Forums

Partner Websites