Skip To Navigation Skip To Content Skip To Footer
    Hire Physicians Who Fit, Succeed and Stay - Recruit a Physician - Jackson Physician Search and MGMA
    Insight Article
    Home > Articles > Article
    Christian Green
    Christian Green, MA

    Connecting the pieces of the health disparities puzzle and addressing health inequities is a perpetual process. The myriad contributing factors to this dearth in care access reflect the issues in our society.

    In a recent Hastings Center health equity summit, “Righting the Wrongs: Tackling Health Inequities,” distinguished social scientist David Williams, MPD, PhD, professor of public health and chair of the department of social and behavioral sciences, Harvard T.H. Chan School of Public Health, pointed to three barriers linked to communication, which are at the heart of health inequity:

    1. Increasing awareness regarding the obstacles disadvantaged racial/ethnic populations face
    2. Creating empathy through stories that resonate with the public
    3. Strengthening the science base, which will help develop the political will to tackle racial and social inequities in healthcare.1

    “The lack of empathy shapes policy preferences,” Williams said. “If we don’t feel the pain, if we don’t have compassion for the suffering of others, we are not supportive of policies to help them.”

    The key, Williams asserted, is to effectively communicate this to all Americans. “How do we talk about these problems in a way that people can connect with, resonate with, and say, ‘No, we can do better as a nation,’” he said.

    Poverty, discrimination and structural racism are the primary factors that contribute to health inequities; however, many other determinants — including literacy, education, income, access to nutritious foods, safe housing and reliable transportation — contribute to poor health outcomes.

    According to Williams, if racial disparities did not play a part in health outcomes, there would be almost 80,000 fewer premature deaths among Black people each year in the United States. That equates to 200 people each day.

    “Can you imagine a fully loaded jumbo jet with 200-plus passengers and crew crashing every day this week, next week, next month, and for a year?,” asked Williams. “Congress would be holding hearings and move heaven and earth to find out why.”2

    If the human cost of unequal care does not capture the public’s attention, the cost to the healthcare system provides another staggering statistic: A 2018 report by the W.K. Kellogg Foundation (WKKF) and Altarum revealed that disparities are responsible for approximately $93 billion in excess medical care costs each year and $42 billion in lost productivity as well as other economic losses due to early deaths.3 

    Integrating social care into healthcare: The 5 As

    One area where health inequities can be addressed is integrating social care into healthcare. Social workers and social care organizations can serve as a bridge between patients and providers by bringing to light the economic, environmental and social factors that influence people’s health.

    “Social workers play a key role by bringing to the table a perspective that reminds us that the system in place has historically, purposely and systematically enacted policies and programs that disenfranchised certain communities,” said Jorge Delva, PhD, MSW, dean of the school of social work and director of the Center for Innovation in Social Work & Health, Boston University, in a 2021 virtual seminar hosted by the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI). “Social workers help de-stigmatize and help people open their minds to the humanity of the individuals we’re working with,”4 he added.

    • Ambulatory integration of medical and social (AIMS) intervention: An example of a standardized model for integrating social work into healthcare settings is Rush University Medical Center’s Ambulatory Integration of Medical and Social (AIMS) intervention, which places social workers into primary and specialty care teams to assist individuals — and their caregivers — with complex biopsychosocial and functional challenges. AIMS is tasked with addressing social needs by integrating medical and non-medical services to improve patient outcomes, which can help reduce the use of costly healthcare services. The model’s objective is to also improve the patient experience. Learn more about the AIMS model.

    More than two and a half years ago, the National Academies of Sciences, Engineering, and Medicine released its consensus report Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. The report found that integrating care that addresses social determinants of health (SDoH) is essential in helping to prevent illness and treating acute and chronic illness. These non-medical barriers can compound medical issues or create new ones, especially for vulnerable populations. In turn, patients often feel stigmatized and don’t discuss the social issues they face with their providers.

    The committee, composed of social workers, nurses and physicians, understood the need for an applicable framework to determine how healthcare delivery systems carry out social care activities. The result was the classification of the “5As” of integration activities, which are designed to address social risks and help improve health outcomes in healthcare organizations by working in tandem with social workers:

    • Awareness: Identifying patients’ and populations’ social risks, needs and assets
    • Adjustment: Reshaping clinical care to accommodate and respond to patients’ social needs
    • Assistance: Connecting patients to applicable social care resources
    • Alignment: Investing in and organizing social care resources to better meet patients’ social needs
    • Advocacy: Advancing policies that create and assign assets and resources to address social needs and minimize social risk factors.5

    Each of these strategies can be applied to specific non-medical barriers, such as lack of reliable transportation, that patients need help overcoming to lead healthier lives. 


    Being aware of a patient’s social environment is essential when recognizing risk factors that can influence the effectiveness of care plans in achieving positive health outcomes. As part of social risk screening, patients can provide information regarding their access to transportation, quality and stability of their housing, and their food security, during each visit or at specific intervals. It’s important to note that simply asking patients about their health-related social needs may not be enough.


    If in-person care is not an option for patients because they don’t have access to transportation, healthcare organizations should research alternatives for care access. In assessing any social risk, such as transportation, providers can use this information as part of the patient’s diagnostic and care plan.

    There are some concerns that telehealth may widen the health equity gap — particularly in communities with higher rates of poverty — due to substandard internet connections, insufficient technology skills or lack of fluency in English, over time; however, it could become a valuable tool in addressing care inequities for those individuals who don’t have access to care or are reluctant to pursue traditional in-person care. As virtual care continues to be refined and the U.S. government continues to invest in broadband expansion, more communities will have access to telehealth.


    Rather than taking full responsibility for patients’ non-medical needs by integrating social workers, it may be easier for healthcare organizations to join with community-based organizations that have the means to focus and address patient social needs. Healthcare organizations may engage in one-time assistance interventions such as directing patients to community resources, referring them to specific social care resources and programs, or handing out transportation vouchers for public transit or ridesharing. This could also entail investing in longer-term interventions such as contracting with a community-based organization that offers transportation services to help improve health outcomes by assisting patients in getting to and from their appointments.


    For healthcare organizations, alignment entails being aware of community care assets and then investing in and partnering with those resources to help improve health outcomes. To maximize alignment, healthcare organizations need to coordinate activity, funding and services, which includes sharing healthcare and social care data with a range of community partners who have access to these data repositories.

    For example, healthcare organizations can invest in community ridesharing programs by partnering with companies such as Lyft or Uber. Some healthcare technology companies have already included a physician ride order feature in their EHRs so that providers can call a ride for patients simply by pushing a button, making it easier for patients to get to and from their appointments.


    Finally, healthcare organizations can partner with social care organizations to further policies that encourage the development and redeployment of resources to improve health outcomes and address social needs. This can be accomplished by using their economic, political and social wherewithal within the community. For example, healthcare organizations can advocate for policies that improve the community’s transportation infrastructure.6

    What’s next?

    As healthcare organizations continue to move toward more value-based arrangements, in which providers take on financial risk for patient outcomes and total cost of care, the integration of the 5As will help serve as motivation for providers to address patients’ unmet social needs.

    To help integrate this framework into healthcare organizations and the healthcare system, the committee suggested focusing on three areas:

    1. Providers and staff should have knowledge of SDoH: Social workers are the experts in social care, and if they are on staff, they can help educate the healthcare team on non-medical factors that influence health outcomes.
    2. Health information technology should be utilized: As social care data becomes more prevalent, healthcare organizations should develop standards for measurement and ensure interoperability between medical providers and social workers.
    3. Financing models: It will be challenging to integrate social care into the legal definition of healthcare in terms of financing. Hurdles also exist in discerning how providers will be incentivized or disincentivized to integrate social care into healthcare delivery, defining how quality and accountability for social care is gauged, determining how care for those with complex social and healthcare needs is paid for, and accounting for the time many social care providers will have to devote to administrative responsibilities.7

    Beyond these integration activities, the committee focused on ways to push the social care and healthcare union forward. What they proposed is similar to what the American Association of Hospital Social Workers reported nearly 100 years ago, in 1928, when it defined social workers’ major contributions to medical care, based on frequency of performance:

    • Attaining information to determine and understand general health issues of the patient
    • Interpretation of the patient’s health issues to the individual, family and community welfare agencies
    • Deploying initiatives to assist the patient and associates.8
    • In looking ahead, the committee came up with five goals designed to improve equity and outcomes:
    • Design healthcare delivery with the integration of social care in mind.
    • Develop a workforce to fuse social care into healthcare.
    • Institute an interoperable digital infrastructure for healthcare and social care organizations.
    • Fund the integration of healthcare and social care.
    • Financially back, conduct and translate research and assess the efficacy of social care practices in healthcare settings.9

    By integrating social workers into healthcare teams and screening for social needs, healthcare organizations can become more knowledgeable about SDoH. In addition, social workers can serve as a bridge between patients and providers by presenting the latter with a snapshot of the patient as a whole person, not just the individual’s clinical condition.

    As Caroline Fichtenberg, PhD, managing director, Social Interventions Research and Evaluation Network (SIREN), University of California, San Francisco, noted in the LDI virtual seminar, screening for social needs “is one of the first ways to bring information about that part of patients’ lives into the clinical setting.” She added that it’s the area where the most research has been done and that “patients are pretty acceptable to being asked about social risks … as long as it’s done in a way that doesn’t feel targeted or stereotyped.”10

    Regrettably, she remarked that integration has been slow to come, because healthcare has been the driver and human service priorities have been relegated to the back seat. For instance, she pointed out that “the healthcare side focuses more on high-cost users, so there’s not as much focus on children,” which is when environmental factors begin to affect an individual’s health, well-being and quality of life. “Ensuring an environment in which children can thrive and develop appropriately is incredibly important to their health in the long run,”11 she added.

    Another reason it’s been a struggle to integrate social care and healthcare, according to Kathleen Noonan, JD, chief executive officer, Camden Coalition of Healthcare Providers, is due to “the lack of support for some patients in perpetuity,” Noonan noted. “The system just loves a program that begins and ends.” 

    The truth is some individuals need continuous care due to the environment they live in. Unfortunately, as Noonan points out, “we don’t really want to grapple with that because it goes against our idea that the system can fix people and then we’re done.”12 

    Health equity is the elephant in the room, but addressing SDoH will go a long way in driving better health outcomes. Deciding where to start is the first step.


    1. Williams D. “How unequal opportunity created unequal health.” Righting the wrongs: Tackling health inequities. The Hastings Center. Jan. 19, 2020. Available from:
    2. Ibid.
    3. Turner A. “The Business case for racial equity: A strategy for growth.” Altarum. April 24, 2018. Available from:
    4. Penn LDI Seminar. Integrating social needs into health care practice: Evidence and barriers. March 7, 2021. Available from:
    5. National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington, D.C.: The National Academies Press. Available from:
    6. Ibid.
    7. Ibid.
    8. American Association of Hospital Social Workers. “1928 Study of 1,000 client cases from 60 social work departments.”
    9. NASEM.
    10. Penn LDI Seminar.
    11. Ibid.
    12. Ibid.
    Christian Green

    Explore Related Content

    More Insight Articles

    Ask MGMA
    An error has occurred. The page may no longer respond until reloaded. Reload 🗙