Five Essential Strategies to Improve Social Determinants of Health to Support Healthy Aging 

Dinning room is our place to spend time

By Halima Ahmadi-Montecalvo, PhD, MPH, Senior Director, Research and Evaluation at Unite Us; Amanda Terry, PhD, MPH, Associate Director, Research and Evaluation at Unite Us

Thanks to better medicine and an overall higher quality of life than in previous generations, many people over the age of 65 today are healthy, living long, productive lives, and aging in place at home rather than moving to institutionalized settings

As we get older, social determinants of health (SDoH)—the conditions in which we live, work, learn, play and pray—play a critical role in our ability to stay active and well. Factors such as the built environment, food and housing security, income, social networks, and access to transportation and health care impact our physical health as well as our mental and emotional well-being. With a growing number of aging people throughout the country, it’s becoming increasingly important to address SDoH with a community-based population health approach. 

Recent data show while 16 percent of the U.S. population is 65 and older today, this number is expected to reach more than 20 percent by 2040 as Gen X reaches retirement age. When SDoH factors create barriers to healthy living within a community, this population represents a significant percentage of those at risk for poor outcomes, which drive preventable healthcare utilization and costs.  

We already know people who live in high-poverty neighborhoods typically experience more stress, health problems, mobility limitations, and health-risk behaviors such as poor diet and physical inactivity. Older adults in these neighborhoods are more likely to have chronic health and mobility issues and die at a younger age compared to their peers who live in more affluent neighborhoods. In fact, roughly 40 percent of those enrolled in Medicare are dealing with four or more chronic conditions, creating issues such as medication nonadherence and co-occurring symptoms requiring frequent, high-cost care. 

Older adults living in high-poverty, rural communities experience more compounding health-related social factors than those in more affluent, suburban and urban neighborhoods. They are often poorer and have more complex health issues, with less health-promoting  infrastructure such as grocery stores, quality housing, recreational facilities and green spaces, quality medical care, and social support networks.  

The lack of social connections is especially troubling considering studies show social relationships can have an equal or even larger impact on health than well-established risk factors like smoking, alcohol consumption, obesity and physical inactivity. The pandemic highlighted the vulnerability of older adults to both social isolation and loneliness.

One of Healthy People 2030’s principles is “the health and well-being of all people and communities are essential to a thriving, equitable society.” To advance health equity for all—including the older adult population—we must provide access to quality, timely healthcare, and manage their SDoH through social care coordination that affords easy access to services they need. 

By mobilizing community partnerships and connecting a network of community-based organizations (CBOs) and care providers through technology that enables timely, equitable care delivery, we can ensure no one falls through the cracks. Here’s how:

1) Conduct thorough needs assessments. The first step to improve community support is identifying community needs and the environmental factors impacting older adults’ overall health. Care coordination platforms allow CBOs to collect data and use those insights to identify gaps and community assets to help fill them. 

2) Facilitate health literacy to drive better outcomes. Health literacy remains a significant obstacle across generations, and older adults who are unaware of the nutrition and lifestyle factors influencing their health are at higher risk for poor outcomes. Providing health literacy materials in a variety of modalities around nutrition, exercise, and lifestyle for both older adults and caretakers, can improve long-term health—both physical and mental.

3) Implement systems change. Access to healthy food, preventive and specialist healthcare, utility payment assistance, transportation, and other health-related social needs remain a challenge for older adults. This may be due to financial constraints, a lack of knowledge of where to go, or the inability to get there because of mobility challenges. While programs do exist to help, connecting older adults with social services is often a cumbersome process. Referrals can’t get to the right providers if those providers don’t talk to each other. Instead, we must implement effective systems that enable streamlined, equitable access to social care services. By leveraging the power of partnerships and mobilizing community networks, we can connect programs and providers on a shared platform to ensure referrals happen in a timely manner with follow-up.

4) Make workforce development a priority. When social care services are unable to provide age-appropriate, culturally sensitive and relevant programming for the populations they serve, individuals face barriers to care and feel their situations and needs are not understood. The public health workforce, including the healthcare workforce, could benefit from enhancements in educational curricula and training programs to address the diversity of care needs among older adults. With 25 percent of older adults identifying as people of color, we must incentivize more people to enter the field and strive to build a more diverse public health workforce to serve this population—one that is well-trained in the special care of older adults.  

5) Continue research to enhance the public health function. With social care platforms which allow us to collect data on intervention outcomes, we can monitor processes and results to ensure quality care delivery. We can identify what works and what doesn’t to optimize services, maximize impact and drive continuous improvement. For example, there are established programs for chronic disease management. Could we leverage those learnings to implement strategies for prevention? Might we take something that’s worked well for diabetes or kidney disease, for example, and apply it to dementia care? We need data to explore these opportunities.

There are real economic benefits to improving how we help aging and older adults apart from the societal implications. By efficiently connecting older adults to primary care and social services that support their overall well-being and mitigate preventable conditions, we can reduce unnecessary healthcare utilization, such as ED visits and hospital readmissions. 

Social determinants of health that create barriers to care and quality of life can be overcome by leveraging social care coordination to provide access to appropriate, timely interventions meeting critical needs. It’s simple: People deserve seamless access to care at every stage of their lives.  

Dr. Halima Ahmadi-Montecalvo is the Senior Director of Research and Evaluation at Unite Us, where she leads evaluation efforts to measure the value of social care investments. Dr. Ahmadi-Montecalvo has extensive experience in the application and use of quantitative and qualitative methodology in behavioral health, and social science broadly.  Her research focuses on the social determinants of health and health inequities, with a particular interest in issues explaining factors within the social and built environment that affect the lives of vulnerable population groups.

She has nearly 20 years of experience in program evaluation, and social and behavioral health research working with local, state, and a number of federal government clients, including the Centers for Medicare & Medicaid Services (CMS); the Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration (HRSA)’s Maternal and Child Health Bureau, the National Institutes of Health (NIH); The Department of Labor (DoL); the U.S. Department of Defense (DoD); and the Veterans Health Administration (VHA).

Dr. Amanda Terry is the Associate Director of Research and Evaluation at Unite Us and supports the company’s efforts to measure the value of social care coordination through cross-sector collaboration. Dr. Terry is a medical anthropologist with nearly 20 years of experience in community engaged research and mixed methods research design. Her research focuses on the social determinants of health associated with maternal and child health outcomes and in chronic disease prevention and management.

Dr. Terry formerly led the National Institutes of Health (NIH)-funded diabetes research program at the University of South Florida (USF) and is a courtesy faculty member in the USF Morsani College of Medicine and USF College of Public Health. She has also been a contributing researcher with the Florida Perinatal Quality Collaborative and a Principal Investigator for the NIH-funded Rare Diseases Clinical Research Network.