Have You Ever Wondered Why Americans Don’t Get Well?

Posted on February 8, 2018

Have you ever questioned why there is an obesity epidemic in America? Or asked why people die from diabetes or suffer strokes from hypertension? Does it make sense that with the number of qualified, board-certified medical providers practicing within the richest country of the world, there should be such widespread illness and disease?

For people who are impoverished or individuals who lack health insurance and access to quality health care, these medical tragedies are very real, but the root causes of our health epidemics do not begin with a lack of access to care. Today’s research dictates that the zip-code you live in is a better predictor of your health than your genetic code. Where you live often dictates whether you can afford prescription medications, find transportation to the doctor’s office, or have a safe place to exercise. Lack of access to nearby grocery stores and fresh fruits and vegetables or an absence of affordable counseling services and stable housing are also barriers preventing patients from achieving good health. These social determinants of health (SDoH) are factors that the Center for Disease Control describe as conditions in which “people live, learn, work, and play (and) affect a wide range of health risks and outcomes.” (https://www.cdc.gov/socialdeterminants/). The impact of a patient’s SDoH is so important that they account for a full 80% of health outcomes (https://www.ncbi.nlm.nih.gov/pubmed/26526164).

Solutions and Partnerships

Stephen F. Austin Community Health Center, Inc., dba Community Health Network (CHN), a federally qualified health center in Brazoria and Galveston counties, has understood the impact of SDoH on patient care and outcomes for several years. High no show rates, noncompliance of medication, patients with perpetual poor diabetic control despite repeated appointment reminders or repeat visits with the primary care provider- something was going on that could not be explained by the care the patients received. The answer was that many patients have many other needs and determinants that affected their health.

CHN is addressing SDoH through care coordination efforts and by partnering with The United Way of Brazoria County (UWBC), to contract with TAVHealth (Triple Aim Ventures, LLC) network with the goal to bring a multitude of health and community partner organizations together on a single platform focused on addressing Brazoria County individuals’ SDoH needs. The UWBC is interested in having all its funded organizations use the TAVHealth network to capture client activities, referrals made and demographic data. “So often times a client may come into your organization for assistance and many different issues present; food insecurity, unstable housing, a mental health issue and we refer the client to a community partner organization. We are unable to follow that client to ensure they received the assistance they needed. The TAVHealth platform will enable organizations to refer, track and share data among both health and non-health entities. Being able to track SDofH will help our Brazoria County residents receive the resources and care they need,” said Jenna Haviland-Alesna, Executive Director of United Way of Brazoria County.


The TAVHealth system has robust reporting capabilities and will identify and substantiate any areas of need in the county. Currently, the project is in the design phase with a goal to deploy the network in March 2019. As Mark Young, CEO of CHN recently stated, “If we, as a healthcare organization, want to improve the health of the individuals we serve, it is imperative that we work with all community partners and service organizations to effect change. It is our belief that Increased collaboration, awareness, and education at the community level will create an environment that supports healthy outcomes.”

TAVHealth is based in San Antonio, Texas.  For more information about their product and services, please visits the website at www.tavhealth.com or contact Spencer Magloff at spencer.magloff@tavhealth.com. Please visit the organization websites at CHN (www.sfachn.org) and UWBC (www.uwbc.org) or contact Penny Pabst at Ppabst@sfachc.org or Jennifer Cobb at jcobb@uwbc.org or for more information about the project.