Social Drivers of Health Resources

General SDoH Resources

• This video, by the American Public Health Association, is part of the series “That’s Public Health” and explains how social determinants of health affect health and well-being.
• Short Video from the Institute for Healthcare Improvement where Rishi Manchanda, MD, MPH, answers the question, “Can you achieve the Triple Aim without addressing the social determinants of health?
• The Social Determinants of Health in Rural Communities Toolkit, by Rural Health Information Hub, consists of 7 modules of evidence-based and promising models and resources to support organizations implementing programs to address social determinants of health in rural communities.
• The social determinants of health topic guide by the Rural Health Information Hub provide an overview of social determinants of health and answers frequently asked questions specific to rural communities.
• Webinar from the Rural Health Research Gateway builds on work conducted by the Rural and Minority Health Research Center. It reviews some elements associated with health across rural populations, such as education, income, and health facility availability.
• The County Health Rankings & Roadmaps report outlines critical steps toward building healthy communities along with some specific policies and programs that can improve health in rural areas.
• The Rural Health Information Hub identifies barriers to healthcare access in rural communities. It provides a toolkit that describes four models and approaches for improving health outcomes and increasing healthcare access to address SDoH.
• This guide provides rural healthcare leaders and teams with foundational knowledge, strategies, and resources to understand the impact of social determinants of health (SDoH) on patients and communities.
• This SHIP webinar focuses on expanding new concepts through the SHIP grant. Madeline Wilson, Quality and Patient Safety Advisory, from the Indiana Hospital Association on Z-Codes and Health Disparities, discusses that Z-codes are an important step in identifying community SDoH that can be used to encourage community healthiness.
• This resource by Healthy People 2030 provides an overview of the social determinants of health, the five domains they can be grouped into, and their impact on people’s health, well-being, and quality of life. It also provides insight into how Healthy People 2030 addresses social determinants of health.
• Various social determinants resources through the American Hospital Association on how hospitals and health systems can address the social determinants in their communities. Also, a Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health features actionable strategies and tools for hospitals, health systems, community organizations, and agencies.
• New Healthy People Infographics: Social Determinants of Health Literature Summaries: Resource provided by the Office of Disease Prevention and Health Promotion (ODPHP) that provides five new social determinants of health infographics, including employment, early childhood development, and education, access to health services, access to foods that support healthy dietary patterns, and civic participation.
• The U.S. Playbook to Address Social Determinants of Health.  The plan sets the stage for structural changes, from the federal to state and community levels, both inside and outside of government. They are meant to address the social needs affecting health outcomes and hindering health equity.  Three pillars would form the initial scaffolding for a nationwide effort: 1) data gathering and sharing; 2) flexible funding for social needs; and 3) support for community-based organizations.

MDHHS SDoH Strategy Resources

• Michigan Department of Health and Human Services Social Determinants of Health Strategy: Michigan’s Roadmap to Health Communities. Addresses the social determinants of health through a collaborative, upstream approach to remove barriers to social and economic opportunity, improve health outcomes, and advance equity.

• Phase II of the MDHHS Social Determinants of Health Strategy (SDoH), Michigan’s Roadmap to Healthy Communities. Phase II of the SDoH Strategy builds on the improvement and alignment efforts of Phase I to advance health equity through structural interventions and multisector collaboration.

• The Michigan Center for Rural Health (MCRH) will provide the Michigan Department of Health and Human Services (MDHHS) with a Rural Health Equity Plan to assess their 2022-2024 Social Determinants of Health (SDoH) Strategy through a rural lens. This plan will identify a list of rural-specific recommendations aligned with the current MDHHS SDoH Strategy.

MCRH RHEP

SDoH Screening Tools

• The Centers for Medicare and Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) made the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool to use in the AHC Model.
• The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE®) is a national effort to help health centers and other providers collect and apply the data they need better to understand their patients’ social drivers of health.

• The Upstream Risks Screening Tool & Guide consists of 28 questions assessing five domains (economic stability, education, social & community context, neighborhood & physical environment, and food).

• The ICD-10-CM Coding for Social Determinants of Health through the American Hospital Association provides an overview of educating key stakeholders on the critical need to screen, document, and code data on patients’ social needs.

Housing Stability

• The U.S. Department of Housing and Urban Development (HUD), in partnership with the United States Interagency Council on Homelessness (USICH) and other federal partners, established All Routes Home: Ending Homelessness in Rural America. This strategy recognizes that strategies for addressing homelessness that works well in urban areas may not be effective in rural areas.
• The National Health Care for the Homeless Council provides several valuable resources that offer insight into serving people in rural.
• Goodwill Northern Michigan operates several community programs and builds systems that help people find homes in Northern Michigan. Their website provides information on the Goodwill Inn emergency shelter, Street Outreach program, other supportive housing programs, and transitional housing community for veterans.
• The Health Resources and Services Administration (HRSA) provides insight into rural housing inequities in rural America.
• Michigan’s Statewide Housing Plan is the first statewide housing plan that acknowledges our state’s challenges but also our assets. This plan addresses complex, intersecting challenges through five statewide housing targets and eight priority areas, with 39 goals, plus 134 suggested strategies for addressing these goals.

Food Security/Health & Wellness Resources

• The Map, the Meal Gap by Feeding America, is a report on county and congressional district food insecurity and county food cost in the United States in 2020. The report focuses on the extent and variation in local food insecurity levels in the U.S. during the first year of the COVID-19 pandemic.
• This United States Department of Agriculture report provides statistics on food security in the United States households throughout 2021 based on the Current Population Survey Food Security Supplement data collected in December 2021.
• The Rural Health Information Hub provides valuable insight into rural hunger and access to healthy food, including frequently asked questions and creative strategies rural communities use to address hunger and food access issues.
• The Food Bank Council of Michigan Distribution map depicts geographic service regions which provide food resources to communities.
• Provides a summary of funding programs offered by the Rural Health Information Hub by State.
• Eat Well in a SNAP is presented by SNAP-Ed at Michigan Fitness Foundation, a collaborative of statewide partners whose work focuses on improving the health of Michigan’s most vulnerable citizens. This resource connects individuals with support and inspiration for recipes, resources, and conversations about food.
• The United States Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion provides resources for specific audiences, including adults, older adults, pregnant and postpartum people, and parents, highlighting simple steps people can take to get active and eat healthy.
• The SNAP-Ed Library by USDA provides resources, including 2023 Guidance on the SNAP-Ed program, low-cost recipes, state programs, nutrition education materials, a seasonal produce guide, and a SNAP-ED Toolkit.
• The Michigan Fitness Foundation (MFF) advocates for the health of Michigan’s residents. This resource provides programs and services focused on food, nutrition, physical activity, and places that allow Michiganders to eat well and be active.
• Michigan Harvest of the Month is a Michigan Fitness Foundation (MFF) program that provides easy, inexpensive meals and side-dish ideas. They aim to inspire active lifestyles and healthy food choices through education, environmental change, community events, and policy leadership

Transportation

• The guide by Rural Health Information Hub focuses on how communities can provide transportation services to support access to rural healthcare and its benefit for healthcare providers. The guide also highlights transportation as a community-based service for seniors and people with disabilities.
• The Rural Transportation Toolkit by Rural Health Information Hub compiles promising models and resources to support organizations implementing transportation programs in rural communities across the United States.
• The Transportation and the Role of Hospitals by the American Hospital Association explain the link between transportation and health and discuss the role of hospitals and health systems in addressing transportation issues, improving access, and helping design and support better transportation options.
• This analysis by the National Rural Health Resource Center aims to determine if there is a relationship between access to transportation and health status.
• A report by the Michigan Health Endowment Fund strives to understand better their role in health-related transportation and lessons learned through previous health-related transportation grants

Safe and Healthy Home Resources

• Michigan lead safe resources through the Michigan Department of Health and Human Services, including drinking water education, where to get blood lead test, available resources to reduce your lead exposure, latest lead testing results in your community water supply, and learn about lead exposure and how you can protect yourself.
• Resources for healthcare providers from the Michigan Department of Health and Human Services, including critical updates, various blood lead reference value resources, blood lead testing recommendations for children and pregnant persons, and Medicaid testing requirements.
• Energy and Weatherization resources through the Michigan Department of Health and Human Services, including Home Heating Credit, State Emergency Relief, and Weatherization Assistance.
• The article explores the intersection of rural housing quality and health, identifying unexplored opportunities to join public health and medical experts to address housing quality

Social Drivers of Health Manager Contact 

Laura Mispelon, MHA
Social Drivers of Health Manager
Michigan Center for Rural Health
laura.mispelon@affiliate.msu.edu