Population Health ASCEND ASCEND: Outfitting for Value-Based Payments | Page 49

Social Determinants of Health
Challenges PYA Services
• Need to identify and address
social determinants of health to
achieve better outcomes and
lower costs • Strategic planning for targeted investments
to address social determinants
• Lack of screening processes to
identify patients’ social needs
• Unfamiliarity with evidence-
based disease self-management
programs
• Limited ability to connect patients
with needed services and
supports
• Guidance on best practices
• Evaluation and implementation of
evidence-based disease self-management
programs
• Facilitation of communications between
healthcare providers and community-
based organizations
• Development of local managed services
networks and accountable health
communities
Understanding and forming connections with community-based
organizations to access social supports for patients
24