Integration of Social and Medical Care

May 2022 Council

Lead Division/Office


Point(s) of Contact

Barbara Linder, M.D., Ph.D.; Pamela Thornton, Ph.D.; Mary Evans, Ph.D.; Jenna Norton, Ph.D., M.P.H.; Kevin Abbott, M.D., M.P.H.; Raquel Greer, M.D., M.H.S.; Ivonne Schulman, M.D.; Robert Rivers, Ph.D.; Katrina Serrano, Ph.D.

Executive Summary

Exposure to health impeding social determinants of health (SDOH) contributes to poor obesity, diabetes, and kidney disease outcomes. Adverse SDOH disproportionately affect economically disadvantaged and minority populations and contribute to avoidable health inequities that characterize NIDDK diseases. The U.S. is currently experiencing a transition to value-based payment models that incentivize health settings to treat the “whole person,” including SDOH. This transition represents an opportunity to effectively address SDOH through novel healthcare delivery models that extend medical care beyond clinic walls into community contexts. However, evidence for how to address social risks in healthcare settings is lacking and current implementation strategies vary across healthcare delivery contexts. This initiative will 1) jump start novel research to systematically screen for and address patients’ social risks to improve health outcomes in NIDDK diseases; and 2) grow a community of NIDDK researchers who can share effective strategies to integrate medical and social care in the context of healthcare delivery. Pilot and feasibility trials funded through this initiative will study interventions that involve screening for and addressing SDOH, through efforts to appropriately refer/navigate patients to resources to address these issues. These pilots will lay the foundation for larger, fully powered clinical trials focused on integration of social and medical care for NIDDK diseases.