How To Identify the Social Determinants of Your Patient Population

Social determinants of health (SDOH) can shape health outcomes in unexpected ways. Discover their impact on diverse patient groups and explore how healthcare providers can identify and address these factors to ensure equal and accessible care for all.

There’s more to a patient’s well-being than just medical treatment. Social determinants of health (SDOH) can affect a person’s health. They include their place of residence, their income, and their education. These factors can influence health and access to healthcare as well as the delivery of care. Therefore, understanding SDOH becomes essential for not only providing sensitive care to patients but also elevating practice operations.

Social determinants and diverse patient populations

Social determinants of health refer to the social, economic, and environmental factors that influence a person’s health and well-being. They include but aren’t limited to:

  • Income: Individuals with higher incomes often have better access to healthcare and healthier living conditions.
  • Education: Education level can impact health outcomes. Higher education is linked to better health knowledge and healthier behaviors.
  • Housing: Safe and stable housing is crucial for maintaining health. Poor housing conditions can lead to a range of health problems.
  • Race/ethnicity: Racial and ethnic disparities in healthcare access and outcomes are well documented. Discrimination and systemic inequities contribute to these disparities.

Ignoring SDOH can have profound consequences for providers and patients. Patients facing SDOH-related barriers may delay seeking care, resulting in more complex health issues and higher treatment costs. They may struggle with medication adherence or follow-up care, leading to poorer health outcomes. In many cases, patients may not have access to the health resources they need, exacerbating conditions that would otherwise be manageable.

Identifying social determinants in your patient population

Identifying SDOH in your patient population helps you provide better care. Here’s how you can get a better idea of your patients’ needs and challenges:

  • Comprehensive patient assessments: Take a holistic approach that goes beyond medical conditions. This can include asking about employment status, educational background and literacy, housing, income and financial stability, food security, transportation availability, and social support networks or relationships.
  • Building patient trust and rapport: Create a culture of open and nonjudgmental communication in your healthcare practice. Patients are more likely to share sensitive information about their social circumstances if they feel safe and respected.
  • Screening tools and questionnaires: Use screening tools and questionnaires to collect data on various SDOH factors systematically. If possible, integrate these tools into your electronic health record (EHR) system to streamline data collection and ensure the information is readily available to healthcare providers during patient visits.
  • Community collaboration: Social workers are trained to assess SDOH and connect patients with appropriate resources. Partnerships with local community organizations and social service agencies can assist patients facing SDOH-related challenges.

Strategies to address SDOH

Once identified, healthcare providers can take proactive steps to address SDOH. Training your staff is critical. Make it a point to acknowledge and respect patient backgrounds and preferences. Once you’ve detected areas of concern, you can design patient-specific treatment plans to consider the social determinants affecting each individual.

Furthermore, you should connect patients with community resources, such as food banks, housing assistance programs, and educational resources. Leveraging EHRs to collect and store SDOH information can also facilitate better-informed care decisions.

Deliver patient-centered care

Ignoring SDOH factors perpetuates health disparities and contributes to systemic inequities in healthcare. By acknowledging the multifaceted variables that shape individuals’ lives beyond the care they receive, providers can bridge gaps, reduce disparities, and offer patient-centered care. Taking the time to better understand your patient populations isn’t just a gateway to delivering better care; it’s a formula for sustainable practice success.

To learn more about understanding your patients and delivering patient-centered care, visit