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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Page R14
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Investing in Interventions That Address Non-Medical, Health-Related Social Needs: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25544.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Investing in Interventions That Address Non- Medical, Health-Related Social Needs PROCEEDINGS OF A WORKSHOP Rose Marie Martinez and Joe Alper, Rapporteurs Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Health. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25544 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Investing in interventions that address non-medical, health-related social needs: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25544. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process, and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

PLANNING COMMITTEE FOR A WORKSHOP ON INVESTING IN INTERVENTIONS THAT ADDRESS NON-MEDICAL, HEALTH-RELATED SOCIAL NEEDS1 DANIEL E. POLSKY (Chair), Bloomberg Distinguished Professor of Health Policy and Economics, Carey School of Business and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University JOHN AUERBACH, President and Chief Executive Officer, Trust for America’s Health SETH A. BERKOWITZ, Assistant Professor of Medicine, Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill DAVE A. CHOKSHI, Chief Population Health Officer, New York Health + Hospitals Corporation DEIDRA CREWS, Associate Professor of Medicine, Department of Medicine, School of Medicine, Johns Hopkins University KAREN B. DESALVO, Professor of Medicine, Dell Medical School, The University of Texas at Austin ARVIN GARG, Associate Professor of Pediatrics, School of Medicine, Boston University MAURICE JONES, President and Chief Executive Officer, Local Initiatives Support Corporation Project Staff ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice ANNA MARTIN, Administrative Assistant Consultant JOE ALPER, Consulting Writer 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS v

Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: Ed Hunter, Ed Hunter Strategies, LLC Lourdes J. Rodriguez, The University of Texas at Austin Uche S. Uchendu, Health Management Associates Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by Harry S. Heiman, Georgia State University. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Acknowledgments The National Academies of Sciences, Engineering, and Medicine wishes to express its sincere gratitude to Daniel Polsky, planning committee chair, for his valuable contributions to the development and orchestration of this workshop and to the members of the planning committee who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, many thanks to the speakers and moderators, who generously shared their expertise and their time with workshop participants, and the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Health, for its support of this workshop. PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Contents ACRONYMS AND ABBREVIATIONS xv 1 INTRODUCTION 1-1 Organization of the Proceedings, 1-2 2 SETTING THE STAGE 2-1 Keynote Address, 2-2 Two Different But Complementary Meanings, 2-7 Addressing Health-Related Social Needs at NYC Health + Hospitals, 2-10 Moving Health Care Upstream in Massachusetts, 2-12 Discussion, 2-13 3 HOUSING INTERVENTIONS 3-1 Accelerating Investments for Healthy Communities, 3-2 Medicaid Accountable Care Organizations, 3-5 Healthy Neighborhoods, Healthy Families, 3-6 Solving America’s Housing Crisis Requires All Hands on Deck, 3-8 Discussion, 3-9 4 INTERVENTIONS ADDRESSING FOOD INSECURITY 4-1 Food Insecurity and Health: Consequences and Interventions, 4-1 A National Vision to Improve Diabetes Health Outcomes Using Food as Medicine, 4-2 A Bold Goal: Improving Health by Addressing Food Insecurity, 4-4 Feeding America: Interventions Addressing Food Insecurity, 4-5 Discussion, 4-6 5 INTERVENTIONS ADDRESSING MULTIPLE SOCIAL NEEDS 5-1 IMPaCT, a Standardized, Scalable Community Health Worker Program, 5-2 Community Aging in Place—Advancing Better Living for Elders (CAPABLE), 5-4 Addressing Social Determinants of Health Through Medical–Legal Partnership, 5-4 CommunityRx: Connecting Health Care to Self-Care, 5-7 Discussion, 5-9 6 RETURN ON INVESTMENT 6-1 Assessing the Value of the Social Determinants of Health, 6-2 Return on Investment at the Center for Medicare & Medicaid Services, 6-4 Beyond the Return on Investment, 6-4 Discussion, 6-5 7 RESEARCH GAPS 7-1 A Research Agenda for Health Care Activities Related to Improving Social Care and Social Conditions, 7-2 Identifying Gaps in Knowledge, 7-4 Data and Research Gaps Hindering Policy Development, 7-5 Discussion, 7-6 PREPUBLICATION COPY: UNCORRECTED PROOFS xi

xii CONTENTS 8 REFLECTIONS ON THE DAY 8-1 REFERENCES R-1 APPENDIXES A Statement of Task A-1 B Workshop Agenda B-1 C Speaker Biographical Sketches C-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

Box, Figures, and Tables BOX 2-1 Population-wide Resources Exist to Address Social Determinants of Health, 2-9 FIGURES 2-1 The many factors that play a role in determining an individual’s health outcomes, 2-3 2-2 Inequalities in life expectancy across counties are large and increasing over time, 2-4 2-3 Visual representation of where the social determinants of health and nonmedical social needs fit on a continuum, 2-8 2-4 The arc of the social determinants of health universe is long, but it bends toward social justice, 2-11 3-1 Health systems invest in a range of housing types, 3-4 3-2 Cross-sector utilization by a Medicaid expansion population, 3-5 3-3 A capital stack structure for improving affordable rental properties, 3-7 4-1 How addressing the social determinants of health can improve health, 4-4 5-1 What patients believe will help them improve their health, 5-3 6-1 A high-level framework to describe the effects of the social determinants of health, 6-2 6-2 Return on investment for three interventions to reduce childhood lead exposure, 6-3 TABLES 3-1 Health Care Systems Committing Resources to Develop Affordable Housing and Who Are Participating in the Accelerating Investments for Healthy Communities Initiative, 3-3 5-1 Three Models of Medical–Legal Partnerships, 5-6 5-2 CommunityRx Trials Under Way, 5-8 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

Acronyms and Abbreviations ACO accountable care organization CAPABLE Community Aging in Place—Advancing Better Living for Elders CDC Center for Disease Control and Prevention CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services DoN determination of need HHS U.S. Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act HUD U.S. Department of Housing and Urban Development IMPaCT Individualized Management for Patient-Centered Targets LISC Local Initiative Support Corporation NCH Nationwide Children’s Hospital NIH National Institutes of Health OECD Organisation for Economic Development and Co-operation ROI return on investment SIREN Social Interventions Research and Evaluation Network SNAP Supplemental Nutrition Assistance Program USDA U.S. Department of Agriculture VA U.S. Department of Veterans Affairs PREPUBLICATION COPY: UNCORRECTED PROOFS xv

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With U.S. health care costs projected to grow at an average rate of 5.5 percent per year from 2018 to 2027, or 0.8 percentage points faster than the gross domestic product, and reach nearly $6.0 trillion per year by 2027, policy makers and a wide range of stakeholders are searching for plausible actions the nation can take to slow this rise and keep health expenditures from consuming an ever greater portion of U.S. economic output. While health care services are essential to heath, there is growing recognition that social determinants of health are important influences on population health. Supporting this idea are estimates that while health care accounts for some 10 to 20 percent of the determinants of health, socioeconomic factors and factors related to the physical environment are estimated to account for up to 50 percent of the determinants of health. Challenges related to the social determinants of health at the individual level include housing insecurity and poor housing quality, food insecurity, limitations in access to transportation, and lack of social support. These social needs affect access to care and health care utilization as well as health outcomes. Health care systems have begun exploring ways to address non-medical, health-related social needs as a way to reduce health care costs.

To explore the potential effect of addressing non-medical health-related social needs on improving population health and reducing health care spending in a value-driven health care delivery system, the National Academies of Science, Engineering, and Medicine held a full-day public workshop titled Investing in Interventions that Address Non-Medical, Health-Related Social Needs on April 26, 2019, in Washington, DC. The objectives of the workshop were to explore effective practices and the supporting evidence base for addressing the non-medical health-related social needs of individuals, such as housing and food insecurities; review assessments of return on investment (ROI) for payers, healthy systems, and communities; and identify gaps and opportunities for research and steps that could help to further the understanding of the ROI on addressing non-medical health-related social needs. This publication summarizes the presentations and discussions from the workshop.

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