Social Determinants of Health

Social determinants of health are the conditions in which people are born, grow, live, work and age. They include socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care. Healthcare providers are increasingly responsible for reaching population health goals while reducing costs and need strategies to identify upstream socioeconomic drivers of poor outcomes and higher costs. Some effective strategies include:
  • Screening patients to identify social needs
  • Collecting and analyzing social determinants of health (SDOH) data and using it to inform interventions
  • Collocating services or strengthening partnerships with other community agencies and organizations that serve the same populations
  • Integrating home visits in the PCMH
  • Assertive case management designed to meet a variety of patient needs 

Social Determinants of Health Resources

Integrating Social Services & Health Health Affairs, April 2020
Social Determinants Resources National Collaborative for Education to Address the Social Determinants of Health National Collaborative for Education to Address the Social Determinants of Health
Providing culturally Appropriate Care American Academy of Pediatrics
Social Determinants of Health Center for Healthcare Strategies
Social Determinants of Health Healthy People 2020

Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business CaseCommonwealth Fund, March 2018
Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper  April 2018
Out of Reach: The High Cost of Housing, National Low Income Housing Coalition 2017
A Compass for Families: Head Start in Rural America Center for American Progress, April 10th2018
2018 County Health Rankings Key Findings Report Robert Wood Johnson Foundation 2018
Addressing Social Determinants Of Health Through Medical-Legal Partnerships Health Affairs, March 2018
FACHC Homeless, Housing Challenged, and Residents of Public Housing Resources
Report spotlights 4 states that finance legal services thru Medicaid payments
National Center for Medical-Legal Partnerships
Screening for Health Harming Legal Needs National Center for Medical-Legal Partnerships
Information Sharing for Medical-Legal Partnerships National Center for Medical-Legal Partnerships
FQHC Partnerships for Food Access Case Studies NACHC
The Social Determinants of Health Healthy People 2020
Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity Kaiser Family Foundation 2017
Progress In Achieving Health Equity Requires Attention To Root Causes, Health Affairs, June 2017
Emerging Trends Could Exacerbate Health Inequities In The United States, Health Affairs, June 2017
Health Equity Data Graphic, Health Affairs, June 2017
Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients, Health Affairs, June 2017
A Conceptual Framework and Path for Integrating Social Determinants of Health into Primary Care Practice, Annals of Family Medicine
Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons from Pediatrics, Patient-Centered Primary Care Collaborative
Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment
The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
Powering Healthier Communities: Community Health Centers Address the Social Determinants of Health November 2010
Enabling services: Gateways to better care Infographic NACHC, May 2016


Visit our Vulnerable Populations Resources and Vulnerable Populations News pages


For more information, contact Erin Sologaistoa at [email protected]