Social Determinants of Health Hierarchy of Needs

Payors and Providers know that when it comes to providing services to people with behavioral health or substance use disorder challenges, planning starts (and ends) with “Maslow’s Hierarchy of Needs, ”which includes safety and the Social Determinants of Health (SDOH) as basic needs. Extensive research and the pandemic have elevated the importance of addressing social determinants of health (SDOH) to improve health and reduce longstanding disparities in health and health care.

As a Certified Behavioral Health Clinic (CCBHC), by addressing the SDOH needs, you are enhancing the quality of life for the people you serve, which can have a significant influence on population health outcomes. Addressing SDOH also allows the CCBHC to actively address disparities of health in your catchment or service area, which is one of the criteria of the CCBHC.

According to the National Conference of State Legislators, “Behavioral health disparities can be found in the U.S. based on age, sex, income, disability status, sexual orientation, language, geographic location and other factors.”

The Centers for Disease Control (CDC) defines SDOH as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” The World Health Organization also provides a definition: “Social determinants of health as the conditions in which people are born, grow, live, work and age.” The circumstances people find themselves in are shaped by the distribution of money, power, and resources at global, national, and local levels.

According to an article on the National Health Institute’s (NIH) website, “Adults who experience prolonged homelessness have mortality rates 3 to 4 times that of the general population.” NIH also reports that research suggests that nearly half of the homeless are aged 50 or more. Chronic diseases appear to be more prominent causes of death among the homeless, indicating the potential need for integrating medical support and end-of-life care for the homeless, according to NIH.

The United States Department of Health and Human Services (HHS) has an initiative called Healthy People 2030, which sets data-driven national objectives to improve health and well-being over the next decade, with SDOH as a key factor in the initiative. Social Determinants of Health here include “social and physical environments that promote good health for all, ”as one of the four overarching goals for the decade.

According to the CDC, Social Determinants of Health are mostly responsible for health inequities –the unfair and avoidable differences in health status seen within and between countries. Addressing health disparities in care is one of the criteria of the Certified Behavioral Health Clinic (CCBHC) treatment model. Besides the Community Health Assessment, the CCBHC is required to execute each year, the CDC offers a tool called “Ten Essential Public Health Services and How They Can Include Addressing Social Determinants of Health Inequities” as a resource for all health care providers invested in quality.

As you develop the initial treatment plan for the clients you serve, the first considerations include those needs on the bottom two tiers of Maslow’s Hierarchy of Needs(chart below): physiological needs, and safety. Upon “initial contact ”the risk assessment is completed. Once ensuring the client is safe, like other BH and SUD treatment models, the CCBHC administers an SDOH assessment as part of its comprehensive assessment. If SDOH needs are identified, the client is referred for case management to address the social determinants of health needs as one of their highest priorities. I recently had the opportunity to talk with Char Groves, EHR Data Analyst, and Kristen Sierra Licensed Program Manager CCBHC/ARMHS/Mobile Services, of “People Incorporated Mental Health Services, ”in Eagan, Minnesota; they shared how they are approaching the hierarchy of needs within their certified CCBHC. “When you’re looking at the hierarchy of needs, you can’t move forward until those are met. So, it’s just embedded into what they do.” said Char Groves.

Both the office-based Intakes and Mobile intakes in the community include an SDOH assessment. Some agencies use an external data base of service organizations such as “help finder, ”which is a free database of social services and health providers that can be searched by zip code. Other CCBHCs use a local database of SDOH providers if their area provides one.
To fulfill the SDOH of the people it serves, People Incorporated Mental Health Services has developed itsown robust data bank of SDOH referral resources, including housing, food insecurities, and economic stability, sorted by service type and county to ease logistical challenges for clients.
This CCBHC has a partnership with social service agencies in its communities, which includes an open line of bidirectional communication. People Incorporated reaches out to procure services to meet the SDOH needs of its clients, and the social service agencies it partners with can refer clients in need of BH and SUD services to People Incorporated. These strong community relationships support win-win-win benefits for the clients, the CCBHC, and the social service agency.
More recently, People Incorporated has started to report their SDOH referral activity to the counties, to support insight into which services are being utilized and by whom. People Incorporated has been able to easily add some fields into their service documentation which enabled them to collect referral data for the counties. When they administer the CMS version of the SDOH screening during intake for state clients, they record which referrals were given to the client and report that back to each county.
People Incorporated has recently started collecting data within their EHR on the SDOH referrals and utilization of services. Looking ahead, People Incorporated plans to see greater positive clinical quality outcomes as the result of the linkage with social service agencies and the enhanced effort to address SDOH needs. The impact of addressing Social Determinants of Health is far reaching, not just for the clients but for the overall population. Going back to the basics of the hierarchy of needs is where treatment begins.
Addressing the Social Determinants of Health improves quality outcomes across the community as well as controlling costs. According to an article from the Kaiser Family Foundation, beyond using SAMHSA CCBHC grant funds or Prospective Payment System reimbursement funding for case management services, there are other ways to pay for connecting the client with SDOH services. This chart below from Kaiser shows Medicaid options to address SDOH.
“The most appropriate question may not be how we can afford to pay for social determinants of health as a health intervention, but whether we can afford not to pay for social determinants of health as a health intervention.” – Dr. Kelly Doran, Bellevue Hospital, New York
CCBHCs are particularly set up to address the SDOH issues because the CCBHC is an integrated, holistic treatment model who “turns no one away” and provides “access through any door. ”By removing the barriers of the social determinants of health, we provide people with a genuine opportunity to heal, to recover, to reduce symptoms, and to live a fuller life.

Mary Givens, MRA
CCBHC Program Manager

Mary Givens has been with Qualifacts for 13 years. She has a Masters in Rehabilitation Administration from the University of San Francisco. Before coming to Qualifacts, Mary was the CEO of a non-profit organization that served IDD, she was the Director of Client Services and a Director of Supported Employment for people with SPMI. Since coming to Qualifacts, she has been a Project Manager for Implementation and a Program Manager of Meaningful Use, and is currently the CCBHC Program Manager.

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