In the ever-evolving landscape of healthcare, there's increasing recognition that a patient’s well-being is shaped by much more than their clinical encounters. A growing body of evidence has made it clear: health outcomes are powerfully influenced by non-medical factors known as social determinants of health (SDOH). For healthcare professionals, understanding and addressing these determinants is not optional—it’s essential.
In this blog post, we’ll explore what SDOH are, how they impact patient outcomes, and why they’re central to achieving health equity and delivering effective care. Whether you're a clinician, administrator, or public health practitioner, recognizing the role of SDOH is key to treating the whole person, not just their symptoms.
What are social determinants of health?
Social determinants of health are the conditions in which people are born, grow, live, work, and age. These factors exist outside the traditional scope of clinical care but significantly shape health outcomes. As defined by the World Health Organization (WHO), SDOH include the "conditions in which people are born, grow, live, work and age, and the wider set of forces and systems shaping the conditions of daily life."
Importantly, SDOH differ from social needs, which refer to immediate, individual-level challenges like food insecurity or housing instability. While social needs affect personal health, social determinants reflect the broader, systemic environment that creates or exacerbates these challenges.
The five key domains of SDOH
To effectively integrate social determinants into care, healthcare professionals must understand their core components. The U.S. Department of Health and Human Services (via Healthy People 2030) categorizes SDOH into five interconnected domains:
1. Economic stability
This domain encompasses factors related to an individual’s financial resources. Stable employment, income level, and the ability to meet basic needs—such as food, housing, and transportation—are essential to maintaining good health. Unemployment or low income is associated with higher stress, limited access to healthcare, and poorer outcomes.
2. Education access and quality
Education influences a person’s health literacy, problem-solving skills, and job opportunities. Lower educational attainment correlates with higher rates of chronic disease, shorter life expectancy, and increased barriers to navigating the healthcare system.
3. Healthcare access and quality
While this may seem more clinical, it still includes social elements such as health insurance coverage, provider availability, and patient trust. People in underserved communities often lack access to culturally competent, affordable, and timely care.
4. Neighborhood and built environment
The environment in which someone lives affects their exposure to health-promoting or health-threatening factors. Safe housing, clean air and water, access to parks, public transit, and walkable neighborhoods are all integral. Substandard housing or unsafe neighborhoods limit healthy choices and increase disease risk.
5. Social and community context
A strong support network and sense of belonging can promote mental health and resilience. Conversely, social isolation, discrimination, and community violence are linked to higher rates of illness, depression, and substance use.
How social determinants impact patient outcomes
Research consistently shows that clinical care accounts for only 10-20% of the modifiable contributors to healthy outcomes. The remaining 80-90% is determined by SDOH, behaviors, and environmental influences. In other words, treating the whole patient requires us to think beyond prescriptions and procedures.
For example, two patients with the same diagnosis—such as diabetes—may have dramatically different outcomes based on where they live, their access to healthy food, or their ability to afford medication. Patients facing food insecurity may struggle to manage blood sugar levels, while others with transportation barriers may miss routine appointments.
ZIP code has been shown to be a better predictor of health outcomes than genetic code. Life expectancy can differ by more than a decade between neighborhoods just a few miles apart due to disparities in income, education, and access to care.
Health equity and the role of SDOH
SDOH are a major contributor to health disparities—the preventable differences in health outcomes across different populations. These disparities disproportionately affect racial and ethnic minorities, low-income groups, and rural communities.
To advance health equity, healthcare systems must address the upstream drivers of illness. For example:
- Indigenous populations may experience higher rates of chronic disease due to historical trauma and limited healthcare access.
- Black Americans have higher maternal mortality rates in part because of systemic racism, implicit bias in care delivery, and environmental stressors.
Efforts to reduce these disparities must include structural changes—investments in education, housing, economic development, and healthcare access—to create environments where health is possible for all.
Integrating SDOH into clinical care
Many health systems are beginning to incorporate SDOH screening and interventions into patient care. This shift toward whole-person care recognizes that addressing social needs is critical for effective treatment.
Screening tools and frameworks
Providers can use standardized tools like:
- PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences)
- AHC Health-Related Social Needs (HRSN) Screening Tool [PDF]
These surveys help identify patients at risk due to food insecurity, housing instability, or social isolation.
Referral and navigation
Once a need is identified, referral systems are crucial. Social workers, care coordinators, and community health workers can connect patients to community-based resources—food pantries, transportation assistance, housing agencies, or legal aid.
Interdisciplinary care
Effective SDOH interventions require collaboration among clinicians, behavioral health providers, social workers, and public health organizations. Teams must work together to create individualized care plans that address both clinical and social barriers.
Policy and systemic approaches to addressing SDOH
While clinical interventions are valuable, broader policy change is essential to make lasting impact. Several national and state-level initiatives aim to tackle SDOH at the systems level:
Government initiatives
- Healthy People 2030 includes SDOH as a foundational pillar for national health improvement.
- Medicaid Section 1115 waivers allow states to test innovative models that use Medicaid funds to support social services like housing or food assistance.
- Accountable Health Communities Model (CMS) integrates social risk screening into Medicare and Medicaid services.
Value-based care models
As payment systems shift from volume to value, providers are incentivized to reduce readmissions and improve population health—goals that are difficult to achieve without addressing SDOH. Programs like ACOs (Accountable Care Organizations) and PCMHs (Patient-Centered Medical Homes) support this integration.
Data collection and community investment
Health systems are using geographic information systems (GIS), patient-reported outcomes, and predictive analytics to identify high-risk communities and target interventions where they’re needed most.
Challenges and barriers in addressing SDOH
Despite momentum, integrating social determinants into healthcare isn’t without challenges:
- Data collection and interoperability: Sharing SDOH data across platforms remains difficult. EHR systems are often not equipped to store or act on social risk data.
- Funding limitations: Many healthcare organizations don’t receive reimbursement for social care activities, making sustainable investment a challenge.
- Time and workforce capacity: Clinicians already face tight schedules and burnout. Expecting them to screen and intervene without team support is unrealistic.
- Overmedicalizing social issues: Some critics argue that turning social challenges into medical diagnoses risks missing the broader picture. Healthcare should be a partner—not a replacement—for social systems.
The future of healthcare and social determinants
Looking ahead, addressing SDOH will continue to be central to health system transformation.
Whole-person care as a standard
The integration of physical, behavioral, and social care will become the new norm. Payers, providers, and policymakers are increasingly aligned around the idea that treating medical conditions without addressing root causes is ineffective.
Technology and innovation
Emerging tools like AI-powered social risk prediction, mobile health platforms, and digital resource referrals are making it easier to screen and connect patients to help. These technologies can scale impact—but must be implemented equitably to avoid widening digital divides.
Public-private partnerships
Collaboration will be key. Healthcare systems, housing authorities, food banks, schools, and nonprofit organizations must align around shared goals to improve population health.
By shifting focus upstream and investing in social determinants, healthcare professionals can make a profound impact—not only in individual lives, but across entire communities.
Social determinants of health and equitable, whole-person care
Social determinants of health shape nearly every aspect of a person’s well-being. For healthcare professionals, recognizing and addressing these factors is not just a moral imperative—it’s a clinical necessity.
By understanding the five core domains of SDOH, integrating social risk screening into practice, and advocating for policy-level changes, clinicians and health leaders can transform care delivery. The path to health equity begins upstream, where housing, education, income, and social support set the stage for lifelong health.
It’s time to expand our view of what it means to care for a patient—because health doesn’t start in the hospital; it starts in our homes, schools, jobs, and neighborhoods.
