Social determinants of health (SDOH) are the non-medical factors that influence health outcomes, encompassing the conditions in which people are born, grow, work, live, and age. These include economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Research consistently shows that social determinants account for 30 to 55 percent of health outcomes, exceeding the impact of clinical care alone.
Healthcare organizations are increasingly screening patients for social determinants such as food insecurity, housing instability, transportation barriers, and social isolation. Standardized screening tools like the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) enable systematic identification of social needs at the point of care. Once identified, care teams can connect patients with community-based organizations that provide food assistance, housing support, legal aid, and other social services.
Addressing social determinants has become a strategic priority for health systems operating under value-based care arrangements, where total cost of care is a key performance measure. Organizations investing in SDOH initiatives report reductions in emergency department utilization, hospital readmissions, and overall healthcare spending. CMS has expanded support for SDOH interventions through waiver programs, quality measure updates, and Z-code documentation guidance, signaling that social determinant screening and referral will increasingly factor into provider reimbursement.