Social Determinants of Health

Many hospitals are addressing social determinants of health to influence population health outcomes. Socioeconomic and environmental factors determine 50 percent of a person's health outcomes. Social determinants are the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes. This includes housing, food security, public safety, transportation, and economic stability. These factors may limit access to services or make it difficult to obtain health resources.

Specific patient populations and conditions

Population health management involves targeting specific patient populations––such as people with diabetes, maternal health issues, or cancer. Providers collaborate to create specific standardized treatment goals and interventions. Hospitals track specific populations through:

  • Detailed reports from health insurers
  • Patient medical records
  • Nurse care managers
  • Community health workers
  • Social workers 

Chris Espersen, HAP Leadership Summit Speaker 2019

Food Insecurity

The direct connection between food security and proper nutrition, and better health is well-documented. Yet, in Pennsylvania, more than one in ten Pennsylvanians are food insecure.

HAP opposes a proposed federal rule that would drastically reduce Broad-based Categorical Eligibility (BBCE) for the Supplemental Nutrition Assistance Program (SNAP). The changes would jeopardize food access and adversely affect children, seniors, and people with disabilities. BBCE gives states the flexibility to determine appropriate income thresholds and extend SNAP benefits to low-income families and individuals who would otherwise struggle to afford food. If approved, the change would:

  • Destabilize families by forcing them to choose between putting food on their table or covering child care, rent, or other basic needs
  • Jeopardize free lunches for children who qualify, and programs that provide nutritious meals for children after school and during the summer

In Pennsylvania,

  • Food insecurity is reduced (by one-fifth overall, and one-third for children) when families get SNAP
  • Compared to low-income adults without SNAP, those who participate in SNAP have 25 percent less in health care expenditures
  • Low-income adults who struggle with chronic disease and participate in SNAP have even greater reductions in health care expenditures 

Health Disparities

HAP developed a county-specific map highlighting which counties are above and below the state mean for greater awareness of health disparities.


HAP Contacts

For more information, contact Robert Shipp III,, vice president, quality and population health. For media inquiries, contact Rachel Moore, director, media relations.

HAP News

April 02, 2020

Medicare’s “Hospitals Without Walls” Policy Takes Effect Immediately

The Centers for Medicare & Medicaid Services announced a new initiative this week to allow hospitals to care for patients and bill Medicare and other government payors when they provide services outside traditional hospital settings. This allows for the use of ambulatory surgery centers that have canceled elective surgeries to be used for COVID-19 patient care. In addition, other non-hospital buildings approved by the state also can be used to help expand patient care areas.

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