How healthcare systems are working to improve population health by addressing social determinants of health.

Accessible and affordable transportation, safe and habitable housing, access to nutritious food, public safety, quality education, and exposure to drugs and violence – these all impact a person’s overall health and wellbeing. Healthcare systems in North America are currently working to improve population health with an emphasis on social determinants of health. Their investment will not only better the patient’s quality of life but also reduce costs to the healthcare system as a whole. Below, we discuss how Health Links in Ontario, Canada and Camden Health Coalition in Camden, New Jersey are tackling social factors to improve healthcare.

Health Links:

Healthcare organizations in Ontario are beginning to recognize the need to address social determinants of health to improve patient care especially for high-needs patients who suffer from many complex conditions. High-needs patients represent 5% of the patient population but use up to 2/3rds of the healthcare budget in Ontario. Ontario Local Health Integration Networks (LHINs) have sensed the urgency to address the most vulnerable patients’ needs differently by creating personalized care plans. The LHINs have implemented two teams, ‘Health Links’ and the ‘Integrated Decision Support’ (IDS) team, to help these patients receive better care. IDS identifies who the vulnerable patients are, while Health Links creates personalized care plans for these patients, manages them, and ensures that they have a care provider who can deliver their treatment plan based on their social context. Health Links teams ensure a patient’s condition does not continue to deteriorate while also avoiding unnecessary and preventable emergency room visits. They also look to better the patient experience by improving access to care and reducing wait times to see a specialist. Prevention of readmissions is achieved through coordinated care provided by hospitals, long-term care homes, community organizations and the patient’s family doctor. As of 2016, 82 Health Links teams exist throughout Ontario to address this need.

Camden Health Coalition:

Camden Health Coalition is another initiative that is working to improve patient care of those who are facing complex social and medical challenges whilst also reducing costs in Camden, New Jersey. The Camden Health Coalition analyzes hospital claims data to try and determine which patients would benefit from improved care in order to reduce costs, and also to improve care coordination among healthcare professionals. Through this initiative, they were able to identify “hotspots” or areas in the city that contained many costly patients who were often repeat visitors to the hospital. A physician, Jeffrey Brenner, had formulated the idea to use data to identify who high-cost users in the area were. In one example, Brenner was able to identify a building in the Camden region where a majority of elderly patients were admitted to the hospital due to serious falls. These falls totalled to about three million dollars in healthcare for the city. Camden Health Coalition has used this information to identify vulnerable populations that needed additional care, and put together personalized healthcare plans for those individuals in order to improve their health outcomes and reduce their healthcare costs.

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Ontario Ministry of Health and Long Term Care. (2016, March 22). Transforming Ontario’s Health Care System. Community Health Links provide coordinated, efficient and effective care to patients with complex needs. Retrieved from

Ontario Ministry of Health and Long Term Care. (2015, February 6). Healthy Change – Community Health Links. Retrieved from