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Addressing unmet social needs has become increasingly recognized as a critical component of effective health care delivery. We know that the everyday conditions in which our patients live and work affects their health.1 A lack of basic resources, such as food and stable housing, increases both the risk of developing chronic medical conditions and presents a substantial barrier to adequate treatment. Thus, in this era of value-based care and shared-savings initiatives, physicians are further incentivized to routinely identify these “upstream” determinants of health as targets for therapeutic intervention. The new Accountable Health Communities (AHC) model proposed by the Centers for Medicare & Medicaid Services (CMS) illustrates this concept by promoting collaboration between clinical practices and community-based services.2 Interventions designed to link patients having unmet social needs with necessary resources in the community represent 1 potential strategy for improving health outcomes and reducing downstream health expenditures among vulnerable populations. However, there are minimal data to support the efficacy of such interventions in real-world practice.3
McMullen AM, Katz MH. Targeting Unmet Social Needs—Next Steps Toward Improving Chronic Disease Management. JAMA Intern Med. 2017;177(2):252–253. doi:10.1001/jamainternmed.2016.7711
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