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New Institute Resources for Advancing Community-Integrated Health Care

Essential hospitals are acutely aware of the burden social determinants of health (SDOH) put on their patients and communities. Within communities served by essential hospitals, 23.9 million individuals live below the poverty line and 10 million individuals struggle with food insecurity. In 2017, three-quarters of essential hospital patients were uninsured or covered by Medicaid or Medicare.

We now know that these and other social, economic, and environmental conditions can account for as much as 50 percent of what determines a person’s health. A lack of safe housing and healthy food, along with other social risk factors, can exacerbate existing health problems and create new ones.

Recognizing the correlation between social needs and health, essential hospitals are committed to advancing efforts to mitigate SDOH. Essential Hospitals Institute — the research, education, dissemination, and leadership development arm of America’s Essential Hospitals — recognizes the importance of this connection and offers resources to support our members’ work in this area.

Building on foundational research conducted in 2016, the Institute launched a 2019 research project to investigate how essential hospitals advance their SDOH efforts. At the conclusion of the project, funded by the Robert Wood Johnson Foundation (RWJF), the Institute developed two resources for essential hospitals working toward community-integrated health care (CIHC).

Presenting the Research Findings

A cumulative report — titled Outside the Hospital Walls: An Update on Essential Hospitals’ Efforts to Improve the Health of Their Communities — presents the Institute’s research on essential hospitals’ SDOH progress since 2016. It presents evidence collected through the 2019 survey and interviews with population health executives, explores these findings, and compares the evidence with prior research. The report highlights both the successes and remaining opportunities for SDOH work at essential hospitals.

Meeting Milestones

The Institute also published an accompanying set of milestones intended to help describe elements of CIHC in actionable components. Building on the diverse portfolio of knowledge from past research, the Milestones for Community-Integrated Health Care at Essential Hospitals document identifies activities in which essential hospitals can engage as they begin to work outside their walls.

The milestones specifically outline aspects of:

  • organizational commitment;
  • workforce development;
  • community engagement;
  • external partnerships;
  • health information technology and data; and
  • finance and investment.

The two resources are complementary, but distinct in structure and purpose. The cumulative report details the data and evidence collected, and the milestones document identifies concise, concrete components of CIHC. Readers will benefit from exploring both documents.

The Institute thanks RWJF for financially supporting this work and acknowledges the contributions of experts who shared insight, as well as survey and interview participants. America’s Essential Hospitals and the Institute remain committed to advancing this work. Additional information and examples can be found on


About the Author

Madeline White is a former research assistant at America's Essential Hospitals.

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