Addressing social determinants of health (SDOH) is essential for improving patient outcomes. These factors, such as socioeconomic status, education, and neighborhood conditions, significantly influence overall health.  While primary care traditionally focuses on diagnosing and treating medical issues through prescriptions, a broader approach is needed. 

Integrating  SDOH into primary care practices allows healthcare providers to promote healthier communities, enhance patient engagement, and improve health outcomes. This article will explore effective strategies for incorporating these determinants into daily practice.

Introduction to Social Determinants of Health

When discussing health, the focus often lands on symptoms, diagnoses, and medications. However, the key to a patient’s well-being may lie beyond pills and test results. This is where social determinants of health come into play.

These non-medical factors shape health outcomes. They include the conditions in which individuals are born, grow, live, work, and age, such as housing, education, income, and social connections.

A study published in The Lancet Healthy Longevity highlights the importance of SDOH. It examined how these factors affect life expectancy and health risks in adults with type 2 diabetes in the UK and the USA. 

The researchers aimed to understand the combined effects of SDOH on health outcomes, utilizing large, nationally representative data sets. Their findings suggest that integrating comprehensive SDOH assessments into diabetes care could help identify vulnerable groups. This approach may also support targeted interventions to reduce health disparities.

This perspective shifts the health narrative. It emphasizes that treating symptoms is not enough. We must also tackle the root causes that hinder individuals from achieving and maintaining good health. Therefore, primary care must broaden its focus beyond prescriptions to include the socioeconomic and environmental contexts that affect each patient.

Going Beyond Prescription Medicine to Deal with Social Determinants in Primary Care

In primary care, addressing social determinants of health is just as critical as writing a prescription. It’s time to expand the care model with actionable, community-driven support:

Screening for Social Needs in Clinical Practice

Addressing SDOH in primary care requires a proactive and structured approach, starting with effective screening. Simply asking patients if they are “okay” is insufficient. 

Instead, validated tools that seamlessly integrate into clinical workflows are essential. These tools help identify challenges like food insecurity, housing instability, and transportation issues, enabling healthcare teams to address these needs holistically.

For example, Patients’ Assets, Risks, and Experiences (PRAPARE) has been successfully implemented in healthcare systems. This was demonstrated in a study conducted by NIH. The study highlighted that integrating PRAPARE directly into electronic medical records enabled clinics to identify critical social risks. These included housing insecurity, unmet medical needs, and food insecurity.

The findings highlight the importance of embedding SDOH assessments into routine care to improve patient outcomes. Implementing these tools effectively requires careful planning to avoid burdening staff or delaying patient care.  

Equally important are training staff on their significance and assigning follow-up responsibilities to case managers or social workers. Ensuring a supportive environment for patients during screenings is also essential. Empathy, confidentiality, and a non-judgmental approach are vital to making patients feel safe. 

Building Multidisciplinary Teams in Primary Care

Addressing SDOH effectively requires a collaborative, team-based approach. Healthcare has become too complex, and patient needs are too diverse, for any single professional to manage all aspects of care. Multidisciplinary teams represent the future of primary care.

Social workers and community health workers play a critical role as frontline connectors between clinical care and the real-world challenges patients face. Social workers excel in managing complex cases involving mental health issues, addiction, abuse, homelessness, and chronic stress.

A special issue published in Taylor & Francis Online highlights how social workers’ holistic, client-centered approach positions them uniquely to address health inequities. By integrating their expertise into healthcare systems, social workers lead efforts to target the root causes of health disparities.

The article says that social workers are promoting equitable outcomes and addressing gaps in care for vulnerable populations. Within this multidisciplinary framework, a DNP family nurse practitioner also holds a uniquely powerful position. 

According to Baylor University, they are trained to deliver comprehensive care across the lifespan, from pediatrics to geriatrics. Beyond managing illness, these nurses are leaders in evidence-based practice, addressing the needs of underserved populations, and advancing nursing innovation. 

Even the strongest internal teams rely on partnerships with community-based organizations (CBOs) to fully address SDOH. Clinics must look beyond their immediate settings to address patients’ broader needs. This includes collaborating with organizations that specialize in food access, housing support, transportation, legal advocacy, and other essential services.

Utilizing Technology and Data

By incorporating SDOH data into clinical workflows, healthcare providers can shift from a reactive model to a proactive, population-level strategy. This approach not only helps the individual patient but also identifies broader patterns across a patient population. Insights derived from these patterns enable healthcare systems to design targeted interventions, allocate resources effectively, and advocate for systemic change.

Electronic health records (EHRs), traditionally focused on clinical data, are increasingly being used to document social needs. Capturing information such as housing status, employment, food access, and transportation barriers in the EHR is essential. It ensures that every member of the care team has a holistic view of the patient’s circumstances.

Large language models (LLMs) are at the forefront of this transformation, as demonstrated in a recent study published in Nature. The study highlights that large LLMs can extract SDOH-related data from unstructured clinical notes in EHRs. This is important because much of this information is currently buried and difficult to access. 

While documenting social needs is critical, predicting them before they cause harm is even better. This is where predictive analytics and risk stratification tools come into play. These technologies use algorithms to identify patients who are most likely to experience poor outcomes based on a mix of clinical and social data. 

FAQs

What role can front-desk and administrative staff play in identifying social determinants of health?

Front-desk staff can spot early signs of social challenges, like frequent cancellations or transportation issues, and flag them for clinical teams. With proper training and screening tools, they help connect patients to the resources they need. This support role is vital in addressing SDOH within a coordinated care setting.

How do you measure the success of SDOH interventions in a primary care setting?

Success is tracked through clinical outcomes (e.g., improved A1c or blood pressure) and non-clinical results like reduced no-shows, successful referrals, or higher patient satisfaction. Consistently following up and closing the loop on referrals is essential to evaluating real impact over time.

How can smaller primary care clinics with limited budgets start addressing SDOH effectively?

Start with simple screening forms during intake to identify social needs. Build partnerships with local nonprofits, apply for grants, and use volunteers or trainees to expand capacity. Focusing on the most common issues first allows small clinics to make meaningful progress without large investments.

Incorporating social determinants of health into primary care is not just an enhancement. It’s a necessity. By recognizing the profound impact of factors like socioeconomic status, housing, and community resources, healthcare providers can move beyond traditional treatment methods. This shift invites a more holistic understanding of health, enabling practitioners to address the root causes of health disparities.

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