Community Partnerships to Address Social Determinants of Health among Older Adults

Focusing on social determinants of health (SDOH) among older adults is key to addressing health disparities, maintaining independence in their homes/communities, improving health outcomes, and avoiding high-cost institutional care. While primary care settings are equipped to meet older adults’ physical health needs, the network of Area Agencies on Aging (AAA) is designed to meet social needs (e.g., transportation, nutrition, caregiver support). Yet, cross-sector community partnerships between AAAs and primary care are rare. This article shares an evaluation of one such partnership, where SDOH screenings were routinely implemented in primary care, yielding social prescribing and direct referral to AAA’s support services. Participants included 385 Medicare beneficiaries (Mage = 72.5), including low-income older adults with multiple health conditions. Implementation successes and barriers were uncovered; nearly 75% had unmet SDOH needs, yet only 9% accepted AAA referral. We propose how the Cooperative Extension System (CES) can serve as an authentic partner to build bridges between primary care, community-based educational programming, and the national network of over 600 AAAs. Aspects of CES can be leveraged through a model of health extension to address older adults’ complex social and functional health needs through community-based healthcare and public health interventions, in the pursuit of health equity across the lifespan.