by Geoffrey W. Rutledge MD, PhD and Julian Rogers

As healthcare providers, it is important to fully comprehend the significance of our patients' social determinants of health (SDoH). Studies estimate that clinical care impacts only 20 percent of county-level variation in health outcomes, while SDoH affects as much as 50 percent. Within SDoH, socioeconomic factors such as poverty, employment and education have the largest impact on health outcomes. 

These non-medical factors encompass a wide array of influences, such as:

• socioeconomic status,
• education level,
• access to healthcare resources,
• employment conditions, and
• social support networks. 

Another helpful way to look at SDoH is to break it down into four major categories:

• Personal characteristics such as race, ethnicity, culture, biological sex, gender identity and sexual preference.
• Economic resources such as educational attainment, employment, income, wealth and housing.
• Built environment such as transportation systems, access to healthy foods and walkability.
• Adverse experiences such as childhood trauma, interpersonal violence, relationship disruption or bereavement.

The U.S. Department of Health and Human Services groups SDoH into five domains:

• Economic Stability,
• Education Access and Quality,
• Health Care Access and Quality,
• Neighborhood and Built Environment, and
• Social and Community Context.

Understanding and addressing these determinants are essential for achieving optimal patient outcomes and promoting health equity.

Why SDoH?

Why should we familiarize ourselves with our patients' SDoH? The answer lies in the profound impact these factors exert on individuals' health status and well-being. By recognizing and acknowledging the social barriers that hinder our patients' ability to maintain good health, we can tailor our interventions and treatments accordingly, thus fostering more effective and patient-centered care.

Practical implementation of SDoH in clinical practice is both feasible and imperative. One efficient way to incorporate SDoH into our care approach is through deliberate, guided virtual conversations. Bring it up. Demand of yourself that you know and can adequately weigh the factors that greatly impact your patients’ current and future health.

How to get the conversation started

When discussing social determinants of health with patients, it's important for physicians to use conversation starters that are empathetic, open-ended, and non-judgmental. Here are some examples of conversation starters for physicians to employ:

1. "I want to make sure I understand your overall health situation better. Can you tell me a bit about your daily life and the factors that might be influencing your health?"

2. "Beyond the medical concerns, I'm interested in understanding any social or environmental factors that may impact your health. Is there anything you feel comfortable sharing with me?"

3. "I believe that understanding the bigger picture of your life can help us provide better care. Are there any challenges you face outside of the clinic that might affect your health?"

4. "Health is influenced by many factors, such as income, housing, and access to healthy food. Have you ever noticed any of these factors affecting your well-being?"

5. "Sometimes, things like employment, education, or community resources can play a role in our health. Are there any specific areas of your life that you think might be impacting your health in any way?"

6. "Your health is important to me, not just during our appointments, but in your everyday life. Is there anything you'd like to share about your living situation, support network, or any concerns you may have?"

7. "We know that health can be influenced by various social factors. Is there anything about your background, family, or community that you think might be worth discussing to help us improve your care?"

The goal is to create a safe and supportive environment where patients feel comfortable sharing their experiences. Active listening and non-judgmental responses are crucial to fostering open communication and understanding the social determinants impacting patients' health.

Our window

As telehealth physicians, we have a rare opportunity to connect with patients remotely, facilitating discussions about their social circumstances. Indeed, we possess a powerful view into our patients’ home lives or other environments that an in-office visit with a physician cannot. Through open and empathetic dialogue, we can elicit valuable information about their living conditions, financial constraints, social support networks, and other pertinent factors that contribute to their overall health profile.

Additionally, integrating an assessment of SDoH into annual wellness visits is highly recommended. These dedicated encounters provide a comprehensive platform to systematically review patients' social determinants, thereby capturing a holistic understanding of their health needs. By routinely including SDoH assessments in our consultations, we demonstrate our commitment to patient-centered care and ensure that critical information is not overlooked.

It's expected

Centers for Medicare and Medicaid Services (CMS) guidelines expect healthcare providers to address and document SDoH. CMS has mandated that hospitals reporting to the Inpatient Quality Reporting (IQR) program submit two new measures, SDoH-1 (Screening for Social Drivers of Health), and SDoH-2 (Screen Positive Rate for Social Drivers of Health).

SDoH-1 seeks to know how many patients have been screened for SDoH, while SDoH-2 wants to know of the screened patients, how many were positive for SDoH. The introduction of these measures is a part of CMS’ efforts to expand the collection, reporting and analysis of standardized data. These measures are voluntary in 2023 and will be required by 2024.

Compliance with these guidelines is not only essential for meeting regulatory requirements but also for enhancing the quality of care we deliver. By adhering to the CMS standards, we signal our dedication to a comprehensive and equitable approach to healthcare delivery, embracing the understanding that health is influenced by a myriad of social factors.

Our awareness of patients' social determinants of health plays a pivotal role in improving healthcare outcomes and advancing health equity. By integrating discussions about SDoH into virtual conversations, annual wellness visits, and adhering to CMS guidelines, we demonstrate our commitment to a patient-centered care model that considers the whole person. Together, let us seize the opportunity to harness the power of SDoH in our clinical practice and strive for equitable healthcare for all.