Health Equity Resources

This page provides an introduction to the concepts of health equity, health disparities, and the social determinants of health (SDOH), and contains tools, articles, and guides on implementing health equity initiatives. These resources have been designed and selected to help Community Health Centers and Primary Care Associations pursue health equity and address health disparities by affecting the social determinants of health in their communities. Please contact the CHAMPS Programs Coordinator, Population Health if you have any questions about these materials or would like to share any other useful resources.

For a compilation of educational resources, please visit the CHAMPS Social Determinants of Health Resources webpage.

Please scroll down or use the links below to explore the following topics:

Introduction

Action Resources for Community Health Centers and Primary Care Associations

Action Resources for Patients and Communities

INTRODUCTION

The Health Equity Institute defines the pursuit of health equity as “efforts to ensure that all people have full and equal access to opportunities that enable them to lead healthy lives.” The World Health Organization (WHO) explains that many groups that experience health inequities – including many poor and marginalized people – lack political, social, or economic power. For this reason, effective and sustainable health interventions must go beyond addressing a particular health inequality and also help to empower the group or groups in question through systemic change.

WHO defines the social determinants of health as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” The social determinants of health are primarily responsible for health disparities, which WHO defines as “unfair and avoidable differences in health status.”

To learn more about the foundations of health equity, health disparities, and the social determinants of health, please see the resources below.

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
The Henry J. Kaiser Family Foundation (2015)
http://kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Provides a comprehensive introduction to social determinants of health and various approaches to addressing them at multiple levels.

Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health
World Health Organization (2008)
http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf
Final report of WHO’s Commission on social determinants of health.

Defining Health Equity
Health Equity Institute
https://healthequity.sfsu.edu/content/defining-health-equity
Offers definitions of and approaches to achieving health equity.

HHS Action Plan to Reduce Racial and Ethnic Health Disparities
Office of Minority Health
https://minorityhealth.hhs.gov/assets/pdf/hhs/HHS_Plan_complete.pdf
Outlines goals and actions the Department of Health and Human Services (HHS) will take to reduce health disparities among racial and ethnic minorities.

Public Health, Environmental and Social Determinants of Health
World Health Organization
www.who.int/phe/en/
A clearinghouse of international news and resources related to addressing the social determinants of health.

Social Determinants of Health
Healthy People 2020
www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Explains the social determinants of health and how they are integrated into the Healthy People 2020 approach.

Unnatural Causes
National Association of County and City Health Officials
www.unnaturalcauses.org
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.

 

ACTION RESOURCES FOR COMMUNITY HEALTH CENTERS AND PRIMARY CARE ASSOCIATIONS

DATA TOOLS AND RESOURCES

Accountable Health Communities (AHC) Model Fact Sheet
Centers for Medicare and Medicaid Services
www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-01-05.html
Explains the AHC model, including its background, purpose, funding impact, and eligibility requirements.

Adolescent and School Health – Health Disparities
Centers for Disease Control and Prevention
www.cdc.gov/healthyyouth/disparities/index.htm
Provides data and resources related to health disparities among youth.

Capturing Social and Behavioral Domains and Measures in Electronic Health Records
Institute of Medicine (2014)
Phase 1: www.nationalacademies.org/hmd/Reports/2014/Capturing-Social-and-Behavioral-Domains-in-Electronic-Health-Records-Phase-1.aspx
Phase 2: www.nationalacademies.org/hmd/Reports/2014/EHRdomains2.aspx
These reports identify social and behavioral domains that are best to be considered in all EHRs, specify criteria for deciding which domains to include, and identify domains that should be included for specific populations.

Children’s HealthWatch Hunger Vital Sign
Feeding America
https://hungerandhealth.feedingamerica.org/resource/childrens-healthwatch-hunger-vital-sign
Two-question screening tool to identify children and households experiencing food insecurity.

Coding Social Determinants of Health for Optimizing Value Infographic
Health Information Technology, Evaluation, and Quality (HITEQ) Center
www.hiteqcenter.org/Resources/ValueBasedPayment/EngaginginValueBasedPaymentModels/TabId/175/ArtMID/1078/ArticleID/353/Coding-Social-Determinants-of-Health-SDH-for-Optimizing-Value.aspx
Infographic for providers explaining how SDOH coding data can be used to benefit not only individual patients but also the broader population being served.

County Health Rankings and Roadmaps
Robert Wood Johnson Foundation
www.countyhealthrankings.org
Provides county rankings by state for health factors and outcomes, as well as community health resources by state.

Disparities in Oral Health
Centers for Disease Control and Prevention
www.cdc.gov/OralHealth/oral_health_disparities
Provides data and resources related to oral health disparities.

Health Disparities Data Widget
Office of Disease Prevention and Health Promotion
www.healthypeople.gov/2020/data-search/health-disparities-data/health-disparities-widget
Widget that allows users to view selected health disparities data related to the Healthy People 2020 Objectives for the Leading Health Indicators (LHIs).

Health Disparities in Cancer
Centers for Disease Control and Prevention
www.cdc.gov/cancer/healthdisparities
Provides data and resources on cancer and cancer screening disparities across population groups.

Patient Centered Assessment Method (PCAM) Online
www.pcamonline.org/about-pcam.html
A tool for medical practitioners to use to identify the social determinants of health affecting their patients.

PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences)
National Association of Community Health Centers
www.nachc.org/research-and-data/prapare
PREPARE is a national effort to help CHCs and other providers collect the data needed to understand and act on their patients’ social determinants of health. Includes an assessment tool, an implementation and action toolkit, Spanish translations, webinars and PowerPoint slides on how to use PREPARE resources like the Electronic Health Record templates, and more.

National Partnership for Action to End Health Disparities (NPA)
Office of Minority Health
https://minorityhealth.hhs.gov/npa
Provides health disparities datasets, data collection tools, resource kits, fact sheets, an online partner search, and more.

Recommended Social and Behavioral Domains and Measures for Electronic Health Records
Institute of Medicine
http://nationalacademies.org/HMD/Activities/PublicHealth/SocialDeterminantsEHR.aspx
Identifies the 12 social determinants of health that should be included in all EHRs as part of Meaningful Use 3.

Social Determinants of Health Maps
Centers for Disease Control and Prevention
www.cdc.gov/dhdsp/maps/social_determinants_maps.htm
Generates U.S. maps illustrating health disparities across counties and states related to poverty, unemployment, high school education, and health insurance coverage.

Tracking Social Determinants of Health Interventions: Health Center Reporting of Non-Health Related Services in the Uniform Data System
Capital Link
http://go.pardot.com/l/149871/2018-04-19/n9m61
Findings from an analysis of health center efforts to impact the non-clinical dimensions of the social determinants of health (SDOH). The report draws on 2015 and 2016 UDS data to establish baselines for the size and scope of programs nationwide, and includes recommendations for tracking and analyzing SDOH data going forward.

Veterans Homelessness Screening Tool
U.S. Veterans Administration
www.orpca.org/VA_Homelessness_Screening_Clinical_Reminder.pdf
Brief screening questionnaire used by VA healthcare professionals to screen for homelessness and housing instability among patients who are veterans.

What are Cancer Disparities?
National Cancer Institute
www.cancer.gov/about-cancer/understanding/disparities/what-are-cancer-disparities-infographic
Infographic illustrating what cancer disparities are, factors that cause them, population-based examples, and how NCI is addressing them.

Youth Screening for Social Determinants of Health
American Academy of Pediatrics
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Social-Determinants-of-Health.aspx
Provides tools for identifying and addressing social determinants of health concerns in children.

 

JOURNAL ARTICLES

The Adolescent “Expanded Medical Home”: School-Based Health Centers Partner with a Primary Care Clinic to Improve Population Health and Mitigate Social Determinants of Health
Journal of the American Board of Family Medicine
Margaret Riley, MD, Anna R. Laurie, MD, Melissa A. Plegue, MA and Caroline R. Richardson, MD (2016)
www.jabfm.org/content/29/3/339.abstract
Explores how a partnership between a primary care practice and several school-based health centers impacted rates of compliance among high-risk adolescent patients.

Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico
Journal of the American Board of Family Medicine
Janet Page-Reeves, PhD, et al. (2016)
www.jabfm.org/content/29/3/414.abstract
Describes the WellRx pilot program, in which primary care providers identified and addressed nonmedical social needs experiences by patients seen in a clinical setting.

Building a Foundation to Reduce Health Inequities: Routine Collection of Sociodemographic Data in Primary Care
Journal of the American Board of Family Medicine
Andrew D. Pinto, MD, CCFP, MSc, et al. (2016)
www.jabfm.org/content/29/3/348.abstract
Describes the methods and results of a program at four health organizations in Toronto that utilized a brief survey to gather data on patients’ social determinants of health and add it to their EHRS.

Community Vital Signs: Taking the Pulse of the Community While Caring for Patients
Journal of the American Board of Family Medicine
Lauren S. Hughes, MD, MPH, MSc, Robert L. Phillips Jr., MD, MSPH, Jennifer E. DeVoe, MD, DPhil and Andrew W. Bazemore, MD, MPH (2016)
www.jabfm.org/content/29/3/419.abstract
Explores how aggregated community-level information about the neighborhoods in which patients live, work, learn, and play can be integrated with patient-level data available through EHRs.

Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth
Journal of the American Board of Family Medicine
Katy B. Kozhimannil, PhD, MPA, Carrie A. Vogelsang, MPH, Rachel R. Hardeman, PhD, MPH and Shailendra Prasad, MD, MPH (2016)
www.jabfm.org/content/29/3/308.abstract
Explores how doulas influence pregnancy and birth outcomes for low-income, racially, and ethnically diverse women by addressing health literacy and improving communication among care team members.

Financial Incentives and Vulnerable Populations – Will Alternative Payment Models Help or Hurt?
The New England Journal of Medicine
Karen E. Joynt Maddox, MD, MPH (2018)
www.nejm.org/doi/full/10.1056/NEJMp1715455
Examines the ways that alternative payment models may affect vulnerable populations, including their impact on care coordination, integration, and provider motivation.

A Glossary for Health Inequities
Journal of Epidemiology and Community Health
I Kawachi, S V Subramanian, N Almeida-Filho (2002)

http://jech.bmj.com/content/56/9/647
Article addressing eight key questions related to health inequities.

The Impact of Community Engagement on Health, Social, and Utilization Outcomes in Depressed, Impoverished Populations: Secondary Findings from a Randomized Trial
Journal of the American Board of Family Medicine
Christine A. Lam, MD, MBA, et al. (2016)
www.jabfm.org/content/29/3/325.abstract
Explores the processes by which low-income patients with depression engage in their care and the benefits offered by different resource enhancement approaches.

Improving Access and Utilization of Data to Support Research and Programs Intended to Eliminate Disparities and Promote Health Equity
Journal of Health Disparities Research and Practice
Rosaly Correa-de-Araujo (2016)
https://digitalscholarship.unlv.edu/jhdrp/vol9/iss6/1
Discusses barriers to the effective use of population health data to address health disparities, and suggests new resources and strategies for maximizing the integration of data science into health systems.

Integrating Social and Medical Data to Improve Population Health: Opportunities and Barriers
Health Affairs
Laura Gottlieb, Rachel Tobey, Jeremy Cantor, Danielle Hessler, Nancy E. Adler (2016)
http://content.healthaffairs.org/content/35/11/2116
Describes the rationale for extracting EHR data on social determinants of health, including the influence of this data on quality improvement initiatives and health care payment reform.

Social Determinants of Health and Primary Care: Intentionality is Key to the Data We Collect and the Interventions We Pursue
Journal of the American Board of Family Medicine
Lauren S. Hughes, MD, MPH, MSc (2016)
www.jabfm.org/content/29/3/297.full
Discusses the ways that social determinants of health (SDOH) data collection and analysis may inform patient care, population health, and policy interventions and establishes the foundation for a robust SDOH research agenda in primary care.

The Social Determinants of Health: It’s Time to Consider the Causes of the Causes
Public Health Reports
Paula Braveman, MD, MPH, and Laura Gottlieb, MD, MPH (2014)
www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696
Provides a detailed overview of research linking various social determinants of health to health disparities and discusses the challenges of conducting such research and proving causality.

 

TRAINING TOOLS

Caring with Compassion Curriculum
University of Michigan Medical School
https://caringwithcompassion.org/about
A training curriculum comprised of online modules, learning games, and implementation resources designed to support health care professionals who care for socioeconomically disadvantaged populations. Introduces the bio-psychosocial model for the provision of personalized care for at-risk patients.

Colorado Equity Action Guide
Colorado Department of Public Health & Environment
https://www.colorado.gov/pacific/cdphe/equity-action-guide
Tools that examine root causes of inequity across Colorado through an in-depth review of community characteristics, stories, and data.

Disparities Leadership Program
The Disparities Solutions Center
https://mghdisparitiessolutions.org/the-dlp
A year-long, hands-on executive education program designed to help health care leaders translate the latest understanding of health disparities into realistic solutions that can be adopted by their organizations.

Health Equity Resources
Institute for Healthcare Improvement
www.ihi.org/Topics/Health-Equity/Pages/default.aspx
Tools, videos, publications, and other resources that tie together health equity and quality improvement efforts.

Roots of Health Inequity
National Association of County and City Health Officials
http://rootsofhealthinequity.org
Online learning collaborative that introduces participants to social processes that produce health inequities, and then helps them strategize ways to act on the root causes of these inequities.

THE SDOH Academy
National Center for Medical-Legal Partnership
http://medical-legalpartnership.org/events/sdoh-academy
A HRSA-funded six-month virtual training series designed to help health centers and primary care associations develop, implement, and sustain social determinants of health interventions in their clinics and communities.

Unnatural Causes
National Association of County and City Health Officials
www.unnaturalcauses.org
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.

 

IMPLEMENTATION MODELS

Accounting for Social Risk Factors in Payment
The National Academies of Sciences, Engineering, and Medicine
http://nationalacademies.org/hmd/Reports/2017/accounting-for-social-risk-factors-in-medicare-payment-5.aspx
Series of five brief consensus reports exploring ways to identify social risk factors that affect the health outcomes of Medicare beneficiaries and methods to account for these factors in payment programs.

Addressing Social Determinants of Health in a Health Care Setting
Center for Health Progress
https://centerforhealthprogress.org/blog/publications/addressing-social-determinants-health-health-care-setting
Report summarizing the results of ten key informant interviews on best practices for integrating social determinants of health interventions into health care settings.

Community Health Centers Leveraging the Social Determinants of Health
Institute for Alternative Futures (2012)
www.altfutures.org/leveragingSDH
This collaborative project includes a report on patterns of activity, lessons, and recommendations for CHCs to effectively leverage social determinants of health (SDOH); a database of CHC SDOH efforts; and 10 CHC SDOH case studies.

Evidence Library
Social Interventions Research and Evaluation Network
https://sirenetwork.ucsf.edu/tools/evidence-library
Contains research articles, issue briefs, reports, and commentaries that either focus on or are relevant to evaluating health care-based interventions that address patients’ social and economic needs.

Health Leads
HealthLeads USA
https://healthleadsusa.org

Works with healthcare organizations to create sustainable, high-impact and cost-effective social needs interventions that connect patients to community-based resources.

Healthy Places: Designing an Active Colorado
Colorado Health Foundation
www.coloradohealth.org/reports/healthy-places
This initiative fosters community-led processes that help Colorado communities become healthier places to live, work, and play by increasing physical activity through the construction of safer and more appealing built environments.

Linking Clinical Care with Community Supports (Linkages) Program
Michigan Primary Care Association, Michigan Health Endowment Fund
www.mpca.net/?page=linkages
This project hires, trains, and integrates Community Health Workers (CHWs) into primary care teams in 16 health centers throughout Michigan. THE CHWs directly support patients by sharing of information and resources for accessing food, housing, social services, and counseling; monitoring patients’ health; and helping increase accountability through individualized patient care plans. This page includes more information about the program as well as a toolkit for CHWs.

Opportunities to Enhance Community-Based Medication Management Strategies for People with Complex Health and Social Needs
Center for Health Care Strategies, Inc.
www.chcs.org/resource/opportunities-to-enhance-community-based-medication-management-strategies-for-people-with-complex-health-and-social-needs
Explores promising practices for medication management to optimize care and outcomes for high-need complex patients.

Prioritizing Social Determinants of Health in Medicaid ACO Programs
Center for Health Care Strategies, Inc.
www.chcs.org/prioritizing-social-determinants-health-medicaid-aco-programs-conversation-two-pioneering-states
Interview discussing Minnesota and Rhode Island’s approaches to using Medicaid accountable care organizations (ACOs) to address social determinants of health as a means of both improving health outcomes and lowering healthcare costs.

Rural Innovation Profile: Medical-Legal Partnership Addresses Social Determinants of Health
FirstHealth of the Carolinas
https://cph.uiowa.edu/ruralhealthvalue/files/FirstHealth-Medical-Legal-Partnership-2017.pdf
This nonprofit health care network integrated a medical-legal partnership, as one of the clinical and community support services, into its chronic care management for low-income chronically-ill patients to reduce the non-medical factors that affect their health outcomes.

Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations
Center for Health Care Strategies, Inc.
www.chcs.org/resource/screening-social-determinants-health-populations-complex-needs-implementation-considerations
Examines how several organizations are assessing and addressing social determinants of health for populations with complex needs, and provides assessment tools created by these organizations to better capture patients’ social needs and barriers to care.

 

ACTION RESOURCES FOR PATIENTS AND COMMUNITIES

Advancing Health Equity: A Critical Thinking Tool for Organizations, Programs, and Individuals Committed to Equity
Colorado School of Public Health
www.publichealthpractice.org/civicrm/event/info?id=407
Flexible online tool that walks users through eight topics of public health processes, each including questions that motivate teams to enhance collaboration and consider how to improve health equity and reduce health disparities via community programs, projects, or policies.

Checking Assumptions to Advance Equity
Office of Health Equity, Colorado Department of Public Health and Environment
https://drive.google.com/file/d/13lGpyKMMoxxIdXEn4pnrRJ0jvfO1UFEV/view
Series of questions and additional resources designed to help government, non-profit, and community-based organizations review how an action or decision might impact the health of groups that are most likely to suffer preventable adverse consequences.

Communities in Action: Pathways to Health Equity
The National Academies of Sciences, Engineering, and Medicine (2017)
www.nap.edu/catalog/24624/communities-in-action-pathways-to-health-equity
Describes origins of and solutions to health inequities in the U.S., with an emphasis on how communities can promote health equity by addressing root causes and structural barriers. Available as a free PDF download or for purchase as a physical or electronic book.

Health Equity Change Makers Toolkit
Office of Minority Health
www.minorityhealth.hhs.gov/changemakers/toolkit.html
Shares stories, tips, and tools from and for individuals working to end health disparities in their communities.

Health Impact Assessment
World Health Organization
www.who.int/hia/en/
Tool for assessing the health impacts of policies, plans, and projects in diverse economic sectors using quantitative, qualitative, and participatory techniques.

Health In All Policies: A Guide for State and Local Governments
American Public Health Association, Public Health Institute, California Department of Public Health (2013)
www.apha.org/topics-and-issues/health-in-all-policies
Provides information on using collaborative approaches to improve population health by embedding health considerations into decision-making processes across a broad range of sectors.

A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease
Centers for Disease Control and Prevention (2013)
www.cdc.gov/nccdphp/dch/pdf/HealthEquityGuide.pdf
Guide designed to assist public health practitioners in local, state, and tribal organizations promote health equity through policy, systems, and environmental improvement strategies, including best practices for strategic organizational capacity building, community engagement, and partnership development.

National Partnership for Action to End Health Disparities (NPA)
Office of Minority Health
https://minorityhealth.hhs.gov/npa
Provides health disparities datasets, data collection tools, resource kits, fact sheets, an online partner search, and more.

Rhode Island’s Health Equity Zones: Addressing Local Problems with Local Solutions
Journal of Health Disparities Research and Practice
Nicole Alexander-Scott et al. (2015)
https://digitalscholarship.unlv.edu/jhdrp/vol9/iss6/5
Describes the strategies and infrastructure developed by the Rhode Island Department of Health to coordinate place-based, community-led initiatives that address the social determinants of health.

A Road Map to Address the Social Determinants of Health Through Community Collaboration
American Academy of Pediatrics
http://pediatrics.aappublications.org/content/136/4/e993
Offers a step-by-step method for developing collaborations between primary care facilities and community organizations to address social determinants for children and families.

Solving the Medication Complexity Conundrum through Community-Based Solutions
Center for Health Care Strategies, Inc.
www.chcs.org/solving-the-medication-complexity-conundrum-through-community-based-solutions
Report discussing opportunities to enhance medication management at the community level.

Unnatural Causes
National Association of County and City Health Officials
www.unnaturalcauses.org
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.

Visit the CHAMPS Offsetting Patient Costs webpage to access resources on making healthcare costs more affordable for low-income patients.