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