80% of health happens outside the clinic—M Health Fairview is responding

Since 2023, M Health Fairview primary care providers have started patient visits with questions about access to stable housing, food, transportation, and community support.

That’s because socioeconomic factors play a large role in health—in fact, nearly 80% of health is influenced by factors outside of clinical care, such as access to safe neighborhoods, water, and housing. M Health Fairview is committed to addressing these social determinants of health in order to support the wellbeing of everyone we serve. That’s a commitment we make in and outside of our clinic and hospital walls.

“Fairview has long been a community-focused system,” said Kim DeRoche, MD, chief of primary care with Fairview Health Services. “Minnesota itself has a community-focused culture. We put the issues that affect a person’s health front and center. It changes the whole conversation if someone doesn’t have a fridge for their insulin or electricity for their nebulizer. We aim to address that first.”

Since we started screening for social determinants of health, more than 111,300 people screened positive for food, housing, financial, or transportation insecurity.

In order to provide the most equitable care possible, we’ve expanded social determinants of health screenings beyond primary care. Now, providers at our 10 hospitals and 60 clinics will ask the question to better identify people in need of support. 

Of course, when we ask about social determinants of health, we want to make sure we have a resource to offer people. In 2024, our food navigator program successfully distributed 6,042 meal bags, and enrolled 1,449 people in long-term programs that gave them money to spend at fresh food markets, medically tailored meals, and more through Fair Table, a program designed to advance food equity and reduce diet-related health disparities.

If you tell your healthcare provider that you’re having difficulty getting the services you need or don’t have access to housing, transportation, or money for utilities, your healthcare provider can offer to have a social worker, care coordinator, or food navigator reach out. The service is confidential.

While we can’t fix every issue that affects health, we’re working hard to either offer resources or connect you to programs. Our care coordinators can help connect you to benefits you already have. For instance, your health insurance might cover rides to medical appointments. Care coordinators are experts at looking into policy details for people. They can also help with applications for community resources.

We are also improving our resource directory to connect patients with community services that address critical needs.