Clinics like yours have long played a role in addressing the social determinants of health (SDOH). The origins of this effort can be traced back to the pioneering work on community-oriented primary care developed over a generation ago that strengthened the link between clinical practice and community action. Today, efforts to transform the health care system are increasingly moving beyond the clinic’s walls to address factors contributing to poor health. This move has broadened our focus from providing health care services to addressing overall health of communities.

The shift in payment from volume-based reimbursement to a system that rewards value, as defined by improvements in health and outcomes, has created opportunities and interest in focusing on population health. In the age of big data and an increased development of health care oriented data tools, there is new emphasis for you to collect and use data to improve health at both the individual and population level.

In partnership with the Blue Shield of California Foundation, we created a learning community of curated experts and resources to help your organization gather the necessary data, build innovative partnerships, and develop long-term solutions to address the upstream factors impacting health of communities you serve.

Building on activities already underway in clinics across California, we hope this program acts as an example of applying assets and expertise to this challenge. We also hope it provides you with ideas to experiment with and helps to clarify your role in addressing SDOH in a sustainable way. CCI continues to engage clinics and community partners today, with the hope of learning how we might better support the health care system in addressing social needs, through offerings such as the Population Health Learning Network, Resilient Beginnings Collaborative and Moving Clinics Upstream.