Addressing Social Determinants of Health in Healthcare

How Allina Health is increasing trust, health outcomes by understanding their patients on a deeper level

By Ellie Ulrich Zuehlke | December 19, 2019

As healthcare providers, we know that the health of our patients is largely determined by factors outside of our hospitals and clinics, and that social and economic determinants, health behaviors and the physical environment significantly drive healthcare outcomes, utilization and costs. However, it is unclear how healthcare can best address these social determinants of health.

At Allina Health, understanding our patients and the whole context of their lives is key to delivering excellent care and improving health. We recognize that factors such as access to food, housing and transportation have a significant impact on health.  We believe that part of providing health care is supporting our patients in addressing their health-related social needs.

As part of this commitment, Allina Health was one of 29 organizations nationwide awarded an Accountable Health Communities cooperative agreement with the Centers for Medicare & Medicaid Services. The model is based on evidence that shows health care providers play an important role in identifying and supporting patients in addressing their barriers to health. The goal is to test whether screening patients with Medicaid and/or Medicare insurance for health-related social needs and connecting patients to community resources affects healthcare quality, utilization and costs.

How does it work?

Through the Accountable Health Communities model, care teams screen patients with Medicare and/or Medicaid insurance in our primary care clinics, three metro hospitals and other clinical care settings for five health-related social needs (using a CMS Accountable Health Communities screening tool):

  • housing instability
  • food insecurity
  • access to transportation
  • difficulty paying for heat, electricity or other utilities
  • concerns about interpersonal safety.

If a patient identifies a need, the care team provides a “community referral summary,” an automatically generated list of community resources tailored to the patient’s needs and produced through a software called NowPow, which is integrated with the electronic medical record. Patients who also identify that they have received care in an emergency department more than two times in the last year are randomized to receive additional assistance navigating community resources.


In the first year, more than 97,000 Allina Health patients completed the screening for health-related social needs through the Accountable Health Communities model. Twenty-two percent of patients screened identified at least one need, with the most frequently identified need being food insecurity (60 percent) followed by housing instability (47 percent).

Consistently screening and providing support for patients with health-related social needs is transformational work for Allina Health.  The Accountable Health Communities model has changed how we support patients. It has broadened our scope of care and helped us get to know our patients on a deeper level, leading to increased trust between the patient and care team, and better health outcomes. This work has also changed how we partner in our communities to support our patients in meeting their health and social needs.

Learn more about how Allina Health is engaging its community to better health outcomes.

The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS – 1P1-17-001 from the U.S. Department of Health & Human Services, Center for Medicare & Medicaid Services.

Categories: Caregiver Readiness, Expert Views

Ellie Ulrich Zuehlke, Director of Community Benefit & Engagement at Allina Health

Ellie Zuehlke is the Director of Community Benefit & Engagement at Allina Health, a large not-for-profit health system dedicated to the prevention and treatment of illness and enhancing the health of individuals, families and communities throughout Minnesota and western Wisconsin. Ellie leads system-wide community benefit, community health improvement, charitable giving, community relations and employee volunteerism for Allina Health. In addition, Ellie leads Allina’s CMS Accountable Health Communities Model to support patients in addressing their health-related social needs through routine screening and connections to community resources. Previously, Ellie worked for nearly a decade in State and Local public health building programs and collaborations related to prevention, wellness, chronic disease management and health equity.

Ellie holds a Master's Degree in Public Health Administration from the University of Minnesota and is active in her community as a lecturer in the U of M School of Public Health, board member for two non-profits, mentor, and volunteer.

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