Partners in Care: The Key to Improving Better Healthcare Outcomes through Social and Behavioral Determinants of Health

by June Simmons, President and CEO, Partners in Care Foundation


Health professionals understand many factors affect a person’s health, and medical treatment alone isn’t always enough to improve one’s health.


This is what makes coming modifications to Medicare Advantage plans so exciting. Beginning in 2019, changes will significantly alter the scope of what can be included in a person’s care.


For example, diabetes patients may respond best to a focused workshop or personal health coach. If medical appointments are frequently missed, the solution may be friendly reminders or transportation help. When the risk is falling, grab bars in a bathroom may qualify as care.


Medicare’s innovative approach recognizes a patient’s social and behavioral determinants of health (SBDOH) are as important as medical concerns are in an exam room.


What are social and behavioral determinants of health?

Social and behavioral determinants of health are defined as non-medical factors in one’s life that impact their health. These can include housing conditions or instability, food insecurity, transportation challenges, interpersonal relationships, social isolation, or an inability to manage one’s chronic conditions.


For over 20 years, Partners in Care has seen how effective addressing SBDOHs can be in the lives of medical patients. During that time, it has developed a network of leading community-based organizations and services, such as Canary Health, that address SBDOH. This makes it easy for physicians, their practices, hospitals, health systems and health plans to implement an effective and far-reaching web of services on behalf of patients and members.


Together, Partners and its network have achieved impressive results, including:

  1. Reductions in hospital re-admissions,
  2. Prevention of nursing home admissions,
  3. Improved clinical outcomes,
  4. Enhanced patient experience in the health system, and most importantly,
  5. Kept people in their homes and communities, thus reducing costly institutional care.


These lead to greater patient satisfaction and reductions in the overall cost of care—two significant outcomes.  Patient activation, timely follow-up visits, preventative and chronic condition screenings, outreach support, and wellness campaigns are positive SBDOH care dimension services — areas in which Partners in Care excels.


To learn more about contracting with Partners in Care and their services, visit


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