June 8, 2022 | Jessica Zeff

5 min read

How to Leverage Social Determinants of Health to Advance Patient Outcomes

When it comes to health care, there are many factors that contribute to the health and well-being of patients and patient populations.  These factors extend beyond the medical care people receive and include social factors that directly shape and impact health outcomes and quality of life. These social factors are known as social determinants of health (SDOH). Things like culture, environment, support, transportation, employment status, housing, food insecurity, all affect how patients engage with and respond to health care and so are social determinants of health.

Understanding and addressing SDOH is so important to the health of our nation that the federal government has issued Healthy People 2030, a federal strategy to improve the health of our population by addressing SDOH.  Healthy People 2030  focuses on five domains, emphasizing SDOH, to drive health outcomes1

  • Education access and quality,
  • Health care access and quality,
  • Neighborhood and built environment,
  • Economic stability, and
  • Social and community context.

This focus is important because, according to the Population Health Institute at the University of Wisconsin, healthy behaviors like diet and physical activity only account for about 30% of health outcomes2. SDOH, on the other hand, account for 70% or more. 

An emphasis on SDOH is particularly important in the drive to understand and mitigate health inequity between patient populations.  Analyses of SDOH can help us better identify and address social barriers to health care which might lead to health disparities.  Think, for example, about health outcomes and the potential for health inequity as a result of the inability to speak or understand English; having a hearing, speech, or visual impairment; or as a result of race; gender; sexual orientation; age.  The analysis of SDOH can help identify policies and supports that promote health equity and those that do not, giving you a more efficient way of meeting your patients’ needs.

How Do Social Determinants Impact Health Outcomes?

Think about it this way–people who are unemployed may also be uninsured.  As a result, they may avoid seeking healthcare because they cannot afford the costs. That means they aren’t getting preventative care or medication that can help them manage their health. And when they do get care, they’re often sicker than they would have been had they been treated earlier, incur higher medical costs, and often take longer to recover.  In this case, the lack of insurance or unemployment are social determinants of health with an adverse impact on the patient population.

Other factors such as the neighborhood, level of education, caregivers can also play a role in health outcomes.  Consider the patient who lives in rural areas with fewer health care specialists or who may need to travel long distances to access health care. Or, the patient with no internet access who cannot research health conditions, medications, or how to access treatment. Or, the patient who misses health care appointments because of lack of transportation.  Or even the elderly patient who has no caregivers to help with mobility and so continuously develops pressure ulcers. These are all examples of social factors (aka, SDOH) that contribute to health outcomes.

Leveraging SDOH to Advance Patient Outcomes 

So how do you leverage social determinants to advance patient outcomes and promote health equity? Well, the good thing is it doesn’t have to be complicated. You can implement formal SDOH screening or assessment in just a few steps: 

  1. Do some research.
  2. Consider the population you serve and where you serve them.
  3. Select a standardized and recognized assessment tool to meet your needs.
  4. Decide how, who, and when the information should be best collected.

There are several screening tools that can be beneficial for incorporating SDOH into your practice, such as the CLEAR Collaboration Toolkit, the Protocol for Responding and Assessing Patients’ Assets, Risks, and Experiences Tool (PRAPARE), and CMS’ Accountable Health Communities Health-Related Social Needs Screening Tool. 

Once you start collecting SDOH data, you want to be able to put it to good use. Analytics tools can be leveraged to predict things like which patients have the highest risk of missed appointments. Factors that might contribute to missed appointments is lack of insurance coverage, limited paid time off from employment, lack of transportation, or even a distrust in the health care system. By analyzing data to determine the reasons for missed appointments in your patient population, you can get a better idea of how likely patients will be to miss appointments. This enables you to actively shape the delivery of services to better engage patients  and deliver the care they need to achieve consistent, positive health outcomes. 

Be Prepared to Provide Solutions 

SDOH can give you a better understanding of the factors that affect patient health outcomes and take steps to reduce any barriers to care. Be prepared to implement a plan to provide resources and support to patients whose circumstances prevent them from getting the medical care they need or from continuing treatment once a need is identified. Point patients in the right direction and be sure to follow up with them at their next appointment. 


1 Healthy People 2030. “Social Determinants of Health.” May 24, 2022.

2 Population Health Institute. “The Other Half of Health: An Introduction to Social Determinants.” November 14, 2017

3 Archives of Public Health. “The influence of education on health: an empirical assessment of OECD countries for the period 1995–2015.” April 6, 2020

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