Social Determinants of Health in Clinical Practice

Social determinants of health (SDOH) — the circumstances in which people are born, grow, live, work, and age — profoundly influence health outcomes. Factors like income level, educational background, neighborhood, and healthcare access affect how well patients manage chronic conditions. For clinicians, integrating social determinants into patient care allows for a more complete approach that directly addresses these underlying influences on health and quality of life.

Why Social Determinants Matter in Healthcare

Research indicates that up to 80% of health outcomes are tied to non-medical factors, with medical care accounting for just 20% of the overall health impact [1]. Addressing these determinants promotes patient engagement, reduces hospitalizations, and lowers healthcare costs by confronting the root causes of health disparities. For example, patients facing food insecurity or housing instability may have a more challenging time managing chronic conditions like diabetes or hypertension, which can lead to poorer outcomes if left unaddressed.
Given these impacts, understanding SDOH aligns with the goals of value-based care models, which reward healthcare providers for enhancing care quality rather than volume. Integrating SDOH into a healthcare practice also supports the shift in medicine toward more holistic, patient-centered care [2].

Screening for Social Determinants of Health

Proactively screening for SDOH during patient visits allows providers to identify needs that could otherwise remain undetected. Various tools and questionnaires, including the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) and the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool, help assess factors like food security, housing stability, and access to transportation [3].
Spotting potential risks early in intake—such as food insecurity—helps ensure patients get connected to resources that support their health. For those managing conditions sensitive to diet, like diabetes or hypertension, access to food assistance can make a significant difference in maintaining stability and reducing complications.

Practical Strategies for Clinicians

Connecting Patients to Community Resources

After recognizing a patient’s social needs, linking them to community resources becomes an important step in providing complete care. Clinicians can team up with social workers, case managers, and community health workers to make sure patients get access to the support they need.

Integrating SDOH in Care Planning

Care plans that factor in social determinants provide a practical view of patients’ lives; for individuals who can’t afford healthy food, offering dietary suggestions based on what’s available at local food pantries can be more helpful. Likewise, offering generic medications or linking patients with financial assistance programs can help them stay on their treatment plans without extra financial stress [4].
Collaborating with Community-Based Organizations (CBOs)

Developing partnerships with local CBOs specializing in food security, housing support, and employment assistance can extend a provider’s ability to offer comprehensive care. By tapping into these networks, providers can ensure patients access the support they need outside the clinic, creating a more integrated healthcare experience.

Utilizing Health Information Technology

Incorporating SDOH data into electronic health records (EHRs) enables providers to monitor social needs over time and track interventions. Technology solutions can support this process, allowing clinicians to integrate screening results and identify trends that may require targeted intervention. Additionally, patient-centered platforms, such as digital referral tools, simplify connecting patients with local social services and support systems.

Addressing Specific Determinants

Food Insecurity: Studies link food insecurity to higher rates of conditions like diabetes and heart disease [5]. Screening should explore whether patients have consistent access to nutritious food and a balanced diet. For those struggling to maintain such access, referrals to food programs, such as the Supplemental Nutrition Assistance Program (SNAP) (opens in a new tab) or meal delivery services, can offer a steady source of healthy meals and support overall health.

Transportation Barriers: Access to transportation can be a major obstacle, especially in rural areas. Solutions like non-emergency medical transportation (NEMT) services (opens in a new tab) or telehealth options can provide reliable support, helping patients keep their healthcare appointments without unnecessary delays. By offering options like NEMT services or telehealth visits, providers can help patients receive timely care, reducing the risk of disease progression associated with missed visits [6].

Housing Instability: Unstable housing complicates managing chronic illnesses by disrupting consistent medication use and regular health check-ups. Connecting these patients with housing support (opens in a new tab) or temporary shelter services can create the stability needed to follow treatment plans more effectively [7].

Screening Tools and Resources

Various screening tools and models are available to support the assessment and integration of SDOH into clinical care. Some widely adopted resources include:

• PRAPARE: Developed by the National Association of Community Health Centers, PRAPARE is a standardized tool for collecting SDOH data to inform patient care and identify intervention opportunities [8].
• Accountable Health Communities Model: This model connects patients to community services based on identified social needs, emphasizing the link between clinical care and social support [9].
• FindHelp.org (opens in a new tab): An online platform that connects users to local social services, including resources for housing, food security, and transportation.

Systemic Change and the Future of SDOH in Healthcare

Often, effective change to address the social determinants of health requires policy shifts. Integrating social factors into value-based care models and increasing funding for social support services can help create a healthcare system better equipped to meet patients’ comprehensive needs. Such changes ensure that healthcare systems prioritize preventive care, promote health equity, and address the root causes of health disparities [10].

Conclusion

Incorporating social determinants of health into clinical practice is essential for addressing the core issues driving health disparities. By screening for SDOH, connecting patients with local resources, and taking a multidisciplinary approach, providers can make meaningful strides toward better care for vulnerable populations. As healthcare continues to evolve, addressing SDOH will be crucial in advancing equitable health outcomes and improving overall patient well-being.

References

1. Magnan, S. 2017. Social Determinants of Health 101 for Health Care: Five Plus Five. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. Social Determinants of Health 101 for Health Care: Five Plus Five (opens in a new tab)
2. Andermann A; CLEAR Collaboration. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ. 2016 Dec 6;188(17-18):E474-E483. doi: 10.1503/cmaj.160177. Epub 2016 Aug 8. PMID: 27503870; PMCID: PMC5135524. Taking action on the social determinants of health in clinical practice: a framework for health professionals (opens in a new tab)
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7. Kreuter MW, Thompson T, McQueen A, Garg R. Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health. Annu Rev Public Health. 2021 Apr 1;42:329-344. DOI: 10.1146/annurev-publhealth-090419-102204. Epub 2021 Dec 16. PMID: 33326298; PMCID: PMC8240195. Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health (opens in a new tab)
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