Bayhealth is breaking down barriers for a healthier community

May 10, 2022

Up to 80 percent of an individual’s health outcome is impacted by their social determinants of health.

These are key areas that include housing, transportation, food insecurity, financial problems, domestic or intimate partner violence, and community or family support. The research in this area and a push to better understand and address it through intervention has been growing nationwide and has been underway at Bayhealth. Tackling the challenges of social determinants of health is an important part of Bayhealth’s commitment to population health and its mission to strengthen the health of the community, one life at a time.

Evidence shows that when individuals struggle with one or more of these factors, or experience poverty in general, they are more likely to lack health insurance and have unmet medical needs, including access to primary care and care coordination. The Centers for Disease Control and Prevention’s Healthy People initiative highlights the significance of addressing social determinants of health to promote good health. The National Association of Accountable Care Organizations also recognizes the importance of recognizing social determinants of health as a leading priority in improving health inequities.

Efforts to address individuals’ social determinants of health began at Bayhealth in 2020 after some team members participated in a national learning collaborative rooted in the concept of doing well by doing good. During a six-month process, Bayhealth collaborated with fellow participant Mount Sinai, New York City’s largest academic health system, and several other health systems from across the U.S. and Puerto Rico to create social determinants of health workflows and methodologies that would best serve their respective patient populations. The Bayhealth group used a screening tool recommended by the Centers for Medicare & Medicaid, and tools in their electronic health record to carry out a process for documenting patients’ social determinants of health needs and referring those patients to community agencies or resources.

At the helm of this important new initiative are Bayhealth’s clinical integration team and a Bayhealth social determinants of health work group that includes multidisciplinary clinical and nonclinical team members from across the organization.

A community outreach committee was formed around the same time that efforts to address social determinants of health took off. Managed by Bayhealth Volunteer Coordinator Carrie Hart, this committee is helping Bayhealth better serve the needs of all community members and working with the social determinants of health work group since the community integration element is key to the success of these efforts specifically.

The work group began with a pilot program within Bayhealth’s cardiovascular service line. It targeted those in the community experiencing heart failure, which has been identified as a priority health concern among individuals in Sussex County.

“Many of our hospitalized heart failure patients were dealing with other challenges in their lives that made it even harder for them to stay healthy. They were referred to the right resources to get the help that they needed, whether it was food from a local food bank or getting transportation to their clinician appointment,” said Tasheema Heyliger, Bayhealth program manager for population health. “There was a 67% decrease in hospital readmissions for heart failure patients. We knew from there we needed to get all units at Bayhealth involved to implement this on a broader scale to help more patients.” 

The pilot program enabled Bayhealth team members to track data for social determinants of health patterns and determine next steps to mitigate their effects on health outcomes for all patient populations. Heyliger said education for clinical and non-clinical team members is a key focus right now. “We want to build upon our progress and ensure that inpatient and outpatient staff are trained on how to elicit a SDoH history, gather data and make appropriate referrals.”

Bayhealth Director of Clinical Integration Evan Polansky, who has been instrumental in moving the social determinants of health efforts forward, explained that only about 10-15% of total care costs in the United States can be addressed by medical interventions alone. “Many other variables in people’s lives influence an individual’s health and therefore tie into the remaining costs of care. Addressing these factors is a vital step in improving health outcomes as well as avoiding unnecessary emergency department visits and hospital readmissions. More importantly, we are here to take care of our patients, so understanding and working to meet all the needs that are impacting their health is the right thing to do.”

To learn more about Bayhealth and all the healthcare services it offers to the community, go to To find a primary care provider or specialist, go to or call the referral line at 1-866-BAY-DOCS (229-3627).

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