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Highlights | July 2020



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It is estimated that 80% of what creates health is shaped by social conditions in which we live, learn, work, and grow.



Olympic Community of Health (OCH) engaged Collaborative Consulting to look at how adverse social conditions across the region are impacting health and explore whether there are opportunities for region-wide, collaborative interventions.

OCH and Collaborative Consulting conducted an environmental scan, literature review, and took stock of available data. The findings from these
activities provided a wide perspective of the various social risk factors and their impact on community health.


Identifying and addressing social conditions that negatively impact health is a priority of OCH. This report is one step in a broader palette of work to support partners in addressing issues no single sector or tribe can tackle alone.


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Interconnected factors that impact health:

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Predispositions to health or disease ingrained in our genes

The daily choices we make that promote or damage health

Availability, use and quality of medical care

Education, employment, income, housing, community safety

Quality of
living and work
pollutants, and

Power influences decision making, resource allocation, what is acceptable in society, and priorities

The term “social determinants of health” is often misinterpreted as being negative or applying to only select groups of people. Everyone’s health, however, is shaped by their social conditions. For some it is positive while for others it is negative.



  • Social determinants (SDoH): The conditions in which people are born, grow, work, live, and age that affect a wide range of health, functional, and quality of life outcomes and risks.

  • Social risk factors: Adverse social conditions that create risk for health, such as poor
    housing or unstable social relationships.

  • Social needs: These differ from social risks by emphasizing the individual’s priorities and preferences of which social interventions they most need and want.



Dominant social needs in the Olympic region (OCH assessment)


OCH and Collaborative Consulting surveyed different partners across the Olympic region to better understand the social needs and social conditions that are negatively impacting health.

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Major needs in the Olympic region:


Sustainable income

Affordable housing

Relative to WA state, unemployment is higher and public assistance income is more prevalent, and at the same time median household incomes are lower. Roughly 1/3 of households spend over 30% of their income on housing, there is an affordable housing shortfall, and an exceedingly small percentage of vacant homes in the region.

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The COVID-19 pandemic amplifies
the need to address social conditions.

“The needs of the
community are even more
dire. People that were
already on the brink now
have become unemployed. ”

- OCH Partner

Across the country COVID-19 is exacerbating social risk factors for millions, including the loss of employment (and health coverage loss), worsening food insecurity, and increasing housing instability, and increase in behavioral health needs.


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Partners were asked to describe their vision for the future related to addressing adverse social conditions.
What emerged is a picture of using partnerships to enhance existing activity to address immediate needs
while simultaneously implementing upstream strategies to address social conditions driving these needs.

The graph below displays partner priorities regarding ease, potential impact, and benefit from
regional response (circle size). Housing instability and employment were identified as social risk factors that would have both great impact and benefit from a regional response.
Here and Now

Oftentimes intervention efforts focus on reacting to immediate social needs, such as providing temporary housing or food, without ever making their way further upstream to prevent the needs. While these activities are necessary and will benefit the individual there are a multitude of opportunities to prevent social needs.

Specific areas partners want to see enhancements:

  • Expand eligibility and increase flexible funding for existing programs.

  • Enhance referral systems and processes to better connect people to community resources.

  • Increase data sharing and communication between clinical and community partners.

  • Increase mental health and substance use disorder services.

Specific areas partners want to see new strategies implemented:

  • Address the underlying conditions of employment, housing, and education.

  • Increase employment opportunities and establish employment programs.Increase access to and availability of affordable housing.

  • Support community driven efforts to address adverse conditions.Support local capacity and self-sufficiency to respond to community needs.


Image by Daryan Shamkhali

“There has to be a collective approach within the community. Coming together and working on the same goals."

Community-Based Organization

“We believe that the continued support of community collaboration provided by the OCH is integral to improving the social and health needs of community members in our region.”

Primary Care Provider

Image by Charles DeLoye
Image by Annie Spratt

“I hope that client’s families can access services much earlier in their process. They can go to someone in the community, sit down, discuss what is going on, come up with a plan, and receive appropriate referrals.”

Behavioral Health Provider

Our Partners
Image by David Marcu



Multi-partner initiatives addressing adverse social conditions are emerging across the country and offer many ideas to adapt and apply to the Olympic region. Over 75 multi-partner initiatives were reviewed, 25 of which were profiled in more depth (see Initiatives to Improve Social Conditions report to learn more).

Four categories of organizing structures emerged from the initiatives reviewed:

  • Programmatic partnership: Partnerships formed around interventions focused on specific social needs.

  • Community connectors: Non-profit organizations that coordinate local interventions, manage a coalition of partners, and leverage funding streams towards unified goals.

  • Anchor organizations: Universities, hospitals, and other enduring organizations that
    use their prominent role in local economies to improve the health of the communities
    where they are based.


  • Community-wide initiatives: Place-based initiatives that address a broad range of upstream social conditions through an integrated portfolio of investments for long-term sustained change.

Advancing Partneships

Initiatives showing promise include these elements:

  • Mobilize a broad range of partners

  • Utilize an integrator organization

  • Design & partner with community

  • Coordinate funding from multiple sources

  • Invest in data sharing

  • Take a long-term view


  • Identify collaboration activities and align partners around shared vision and strategy.

  • Coordinate partners to maximize resources.

  • Build collective power to advocate for funding.

  • Facilitate communication and decision making among partners.

  • Provide staff, infrastructure, and data support to manage cross-partner efforts.

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More Info


  1. McGinnis JM, Williams-Russo P, Knickman J. The Case for More Active Policy Attention to Health Promotion. Health Affairs. Mar-Apr 2002;21(2):78-93.

  2. National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington, DC: The National Academies Press.

  3. Murray G, Rodriguez H, Lewis V. Upstream with A Small Paddle: How ACOs Are Working Against The Current To Meet Patients’ Social Needs. Health Affairs. Feb 2020; 39(2).

  4. Virginia Commonwealth University. Uneven Opportunities: How Conditions for Wellness Vary Across the Metropolitan Washington Region. Oct 2018.

  5. Nichols L, Taylor L. Social Determinants as Public Goods: A New Approach To Financing Key Investments In Healthy Communities. Health Affairs. August 2018; 37(8).

  6. Norris T, Howard T. Can Hospital’s Heal America’s Communities? All In for Mission is the Emerging Model for Impact. Democracy Collabora-tive. Nov 2019. Accessed March 2020.

  7. Dahlgren G, Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies. 1991.

  8. Cubbin C, et al. Where We Live Matters For Our Health: Neighborhoods and Health. Robert Wood Johnson Foundation Commission to Build a Healthier America. Issue Brief 3: Neighborhoods and Health. Sept 2008.

  9. Givens M, Kindig D, Tran Inzeo P, Faust V. Power: The Most Fundamental Cause of Health Inequity? Health Affairs Blog. Feb 2018.

  10. Healthy People 2020. Social Determinants of Health. Accessed March 2020.

  11. Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.

  12. Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. KFF Issue Brief. May 2018. Accessed April 2020.

  13. Bartash, J. U.S. jobless claims climb 3.8 million in late April to push coronavirus total to 30 million. Marketwatch. Published 30 April 2020. Accessed June 2020.

  14. U.S. News and World Report. Healthiest Communities Rankings 2019: Measuring health and wellness across the U.S. using 81 metrics. Data Explorer. Accessed April 2020.

  15. County Health Rankings & Roadmaps: Building a Culture of Health, County by County. Robert Wood Johnson Foundation. Accessed Feb 2020.

  16. Center for Healthcare Strategies. Medicaid’s Role in the Next Phase of COVID-19 Response. Part II-Reopening the Healthcare Delivery System. April 2020. Accessed April 2020.

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