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, Healthy People 2020

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


For more information, contact Erin Sologaistoa at