As healthcare systems continue to shift toward value-based care, assessed and addressing social determinants of health (SDOH), like food insecurity, housing instability, and lack of transportation has become a critical strategy for improving health outcomes. For rural communities, which often contend with limited health infrastructure and a range of unmet SDOH, rural hospitals play a pivotal role in recognizing and responding to these conditions that influence the health outcomes of the population they serve.

In our study in the Journal of Public Health Management and Practice, we analyzed how 53 rural hospitals across Iowa identified social needs and addressed them using their Community Health Needs Assessments (CHNAs) and corresponding implementation plans. By examining to what extent hospitals assess SDOH and translate them into action, this study offers insights into the current state of rural hospital engagement with SDOH and where opportunities remain.

Why CHNAs Matter

Non-profit and non-federal government hospitals are required to conduct CHNAs every three years, outlining the health needs of their communities and developing action plans to address them, including social needs. These documents offer a unique window into how rural hospitals assess their population social needs and address them through community partnerships.

What We Found

• Most rural hospitals assessed key SDOH such as food insecurity, transportation challenges, and housing insecurity in their CHNAs, and these were also the most commonly addressed needs in their implementation plans. However, fewer hospitals included specific strategies to address these needs in their implementation plans compared to how often they were assessed.
• Hospitals frequently partnered with schools, local organizations, and faith-based institutions to implement strategies.
• Non-profit hospitals showed higher percentages of both assessment and implementation of SDOH strategies compared to non-federal government hospitals, possibly due to differences in governance structures, available resources, or financial constraints.
• Critical Access Hospitals (CAH) had lower percentages of SDOH assessment and implementation than Prospective Payment System (PPS) hospitals or hospitals affiliated with Accountable Care Organizations.
• Specifically for transportation and housing, significantly higher percentages of Accountable Care Organizations (ACO)-participating hospitals assessed and addressed these social needs compared to non-ACO hospitals.

Interestingly, we also found that even in counties with greater challenges related to SDOH, hospitals were not necessarily more likely to implement strategies in response, suggesting that capacity and resources, not just need, may determine whether action is taken by the hospitals.

Implications for Rural Health Equity

This study reveals a critical gap between recognizing social needs and acting on them. While rural hospitals are clearly aware of the challenges their communities face, limited resources, staffing constraints, and lack of formal partnerships may hinder their ability to respond.

To better support these hospitals, we recommend:

• Expanding infrastructure support for rural hospitals to implement SDOH strategies.
• Strengthening hospital-community partnerships, particularly with trusted organizations like faith-based groups, schools, and local public health departments.
• Enhancing financial and policy incentives that reward hospitals for screening and especially addressing SDOH, especially in low-resource settings.
• Evaluating the outcomes of implemented SDOH strategies to ensure community investments translate into health improvements.

Why This Matters Now

With recent updates to CMS quality reporting requirements that encourage SDOH screening and increasing interest in addressing health inequities (and SDOH related inequities) at the community level our study provides timely insights into the current state of how rural hospitals are identifying and addressing to key SDOH. But identifying needs is just the first step. Without adequate funding, infrastructure, and cross-sector collaboration, hospitals may struggle to close the loop and deliver meaningful interventions addressing SDOH.

Read More

To learn more about the study findings and implications, read our article Addressing Social Determinants of Health in Rural Iowa Hospitals: Content Analysis of Community Health Needs Assessments.

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