Addressing the Social Determinants of Health: The Rhode Island State Innovation Model (RI SIM) Experience.

Addressing social determinants of health (SDOH) is important for improving health and reducing longstanding disparities in health and health care. There is growing interest in standardizing SDOH measures and assessment tools for clinicians to help improve health outcomes. In 2015, Rhode Island received a $20 million State Innovation Model Test Grant (RI SIM) from the Centers for Medicare and Medicaid Services (CMS) to carry out health system transformation and to improve population health. As a part of RI SIM's work, state and community partners began the development of an integrated, coordinated, statewide social services directory infrastructure for addressing SDOH. The goal is to transition this project from resource directory development to a broader eReferral system over the next few years. Tracking referral outcomes will improve coordination of care and will also provide data on capacity of services and help to direct policy and funding allocation decisions at the state level.