Shane Reeves
As a pharmacist and Tennessee state senator, I’ve seen firsthand how healthcare quality — or the lack of it — impacts lives. It’s easy to assume that America has one of the best healthcare systems, but for many, especially here in Tennessee, that’s far from reality.
Tennessee is struggling. We rank near the bottom in almost every major health metric. Chronic conditions like heart disease, cancer, and diabetes are alarmingly high. Infant mortality rates are heartbreaking. Life expectancy? More than three years below the national average. And while Tennessee is among the worst states, poor health outcomes are a reality across the US.
So, what’s going on? Lifestyle choices like poor diet, smoking, and lack of exercise play a role, but there’s more to it: social determinants of health (SDoH) drive up negative health outcomes. This is where we must turn our focus to make a difference.
The role of social determinants of health
It’s well-documented that SDoH have a profound impact on people’s lives. Between 30% and 50% of poor health outcomes are tied to social factors, surpassing the impact of genetics or healthcare access. And in regions like Tennessee, our number is on the higher end of the spectrum.
Economic disparities contribute to healthcare inequality in urban areas like Nashville. But rural populations are hit hardest, facing challenges that extend far beyond the clinic doors: poverty, lack of transportation, and limited education. Across the state, almost 57% of Tennesseeans face at least one SDoH, and over a third face multiple social risk factors.
However, these issues are not confined to Tennessee. Almost 1 in 10 Americans live in poverty, 1 in 7 experience food insecurity, and 1 in 4 are socially isolated. So, what can we do to fix this? The good news is that there are solutions, and they’re already making an impact right here in Tennessee.
What has worked in Tennessee — and what can be replicated nationally
1. Screening for social determinants: One thing we can do — right now — is start screening for SDoH during patient visits. Tools like PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) can help track things like food security, housing stability, and access to transportation.
Once we know what people are facing, we can take action and tackle these issues head-on. Tennessee’s Medicaid Program, TennCare, is already integrating SDoH screening into routine visits. TennCare collaborates with community health workers and uses data analytics to identify at-risk populations, particularly in rural areas. Early results indicate improved access to preventive services, and Medicaid programs nationwide can adopt similar strategies.
2. Addressing preventative care: While SoHD screenings can improve preventative care, we must do more. Community-based preventive programs, like free or low-cost vaccinations, health screenings, and fitness classes, are crucial for addressing health disparities before they become serious.
Additionally, hospitals can work with local markets to offer fresh produce vouchers to patients facing food insecurity. Nashville General Hospital is already doing this under its Food Pharmacy initiative, which provides 12 weeks of free food for patients in need. Tackling health problems like diabetes and heart disease starts with making healthy food accessible to everyone.
3. Hospitals as community anchors: We also need to rethink the role of hospitals in our communities. Hospitals can be more than places where people go when sick. By investing in local community benefit programs, they can be engines of social change. Even simple changes, such as entering ride-sharing partnerships with companies like Uber or Lyft, can help patients without transportation get to medical appointments — a breakthrough for people in underserved communities who otherwise couldn’t access care.
Larger hospitals can make bigger investments towards affordable housing and public health campaigns. Imagine the ripple effect of a hospital working hand-in-hand with local businesses to support economic development. And it’s not just theory — studies show that when hospitals act as “anchor institutions,” they help create jobs, improve care access, and ultimately boost overall health.
4. Integrating care teams: Another promising strategy is the integration of multidisciplinary teams. Doctors, nurses, nutritionists, social workers, and mental health professionals must collaborate to address medical and social factors of health.
For example, patient navigators can help people overcome barriers like transportation or language, improving access to services. Integrating mental health services into primary care is equally vital, as issues like unemployment or housing instability often correlate with mental health struggles. Combine that with community health workers, who act as bridges between the healthcare system and patients, and you’ve got a powerful solution.
Social prescribing further strengthens this model, allowing doctors to “prescribe” non-medical interventions — like exercise programs or community activities — that improve SDoH. Closed-loop referrals ensure patients follow up on their referred services so no one falls through the cracks.
5. Improving health literacy: We must work to improve health literacy. Almost 90% of American adults struggle to understand medical terms and instructions. This directly relates to poor health outcomes—in Tennessee, adults with difficulty getting or understanding health information are three times more likely to have cardiovascular disease.
Healthcare systems can tackle this by providing materials in multiple languages and appropriate reading levels. Digital tools, like mobile apps, telehealth services, and online portals, also make it easier for patients to access information, especially for those with limited mobility or education.
6. Changing the system: Finally, healthcare organizations have the power—and the responsibility—to advocate for public policies that address the root causes of poor health. This includes advocating for affordable housing, transportation infrastructure, and minimum wage increases.
In addition, payment reform is key. Shifting from fee-for-service models to value-based care encourages providers to prioritize better outcomes over the sheer volume of services. This shift will incentivize providers to invest in the social supports their patients need to thrive, such as preventive care, mental health services, and access to healthy food.
Americans everywhere deserve more
While Tennessee still faces significant healthcare challenges, the lessons we’re learning here can be replicated across the country. By focusing on integrating care teams, expanding community programs, and addressing SDoH through policy reform, we can create a healthcare system that serves all patients — especially those most in need.
This patient-centered approach is the future of healthcare. If we commit to these changes now, the benefits will extend far beyond Tennessee, transforming the health of communities across America.
Photo: Liana Nagieva, Getty Images
As Chief Executive Officer of TwelveStone Health Partners, Shane Reeves leads all aspects of the business, including product, marketing, sales, finance, and delivery strategy. Shane’s career began with the organization in 1994 when he joined the family business and worked his way up through every function in the company. Under Shane’s leadership, moving forward as TwelveStone, the organization has grown into a broad medical service company with a long list of clients across the entire care continuum.
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