13 Aug 2025

Using SDOH Screening to Support Health Equity Initiatives

Across the United States, advancing health equity has become a central mission for healthcare systems, public health agencies, and community-based organizations. As providers and policymakers strive to create more just and equitable systems of care, understanding and addressing social determinants of health (SDOH) is emerging as one of the most powerful strategies.

While clinical innovations and new treatment protocols are vital, they often overlook the everyday social and economic factors that heavily influence an individual's ability to achieve good health. By integrating SDOH screening into routine care, healthcare organizations can identify these root causes, tailor support, and make measurable progress toward eliminating disparities.

Health Equity and SDOH: An Inseparable Connection

Health equity refers to the attainment of the highest level of health for all individuals, regardless of their race, ethnicity, income, gender, geography, or other social determinants. Achieving this goal requires addressing systemic barriers and ensuring that every person has fair access to the resources and opportunities needed for good health.

Social determinants of health — such as access to safe housing, nutritious food, reliable transportation, stable employment, and social support — are deeply intertwined with health equity outcomes. Individuals from historically marginalized communities often face disproportionate challenges in these areas, leading to higher rates of chronic disease, preventable hospitalizations, and lower life expectancy.

The Role of SDOH Screening in Advancing Equity

Traditional healthcare models focus heavily on clinical care while often neglecting upstream social and economic factors. By integrating SDOH screening into clinical workflows and community health programs, organizations can systematically identify the non-medical drivers of poor health outcomes.

Key benefits include :

Identifying unmet needs. Screening reveals issues like food insecurity or housing instability that may not be disclosed during standard clinical visits.
Enabling tailored interventions. Once needs are identified, providers can connect individuals to targeted resources and community services.
Tracking disparities. Aggregated SDOH data enables organizations to identify which groups are most affected and track progress in reducing inequalities over time.

Embedding SDOH Screening in Care Workflows

For SDOH screening to effectively support health equity, it must be embedded into everyday care, rather than treated as an optional add-on. This means incorporating social needs assessments into :

New patient intakes.
Annual wellness visits.
Chronic disease management appointments.
Emergency department encounters.

When appropriately integrated, screening can become a natural part of the patient-provider relationship, fostering trust and opening up honest conversations about barriers to health.

Leveraging Data to Inform Community Strategies

Collecting SDOH data at scale allows healthcare systems to move from individual-level support to broader community interventions. By analyzing patterns and trends, organizations can:

Identify neighborhoods with high rates of housing insecurity and collaborate with local housing authorities to address these issues.
Discover food deserts and partner with community organizations to establish mobile markets or food delivery programs.
Understand transportation barriers and advocate for the expansion of public transit routes or rideshare support.

This data-driven approach ensures that resources are allocated to where they are needed most, making equity initiatives more impactful and sustainable.

Strengthening Community Partnerships

Addressing the social determinants of health and advancing health equity cannot be achieved solely by healthcare systems. It requires strong, collaborative relationships with community-based organizations (CBOs), public health departments, housing agencies, food assistance programs, and other local stakeholders.

Through closed-loop referral systems, healthcare providers can ensure that patients not only receive referrals to social services but that these referrals are completed and outcomes are tracked. This enhances accountability, improves service delivery, and strengthens trust among patients and community partners alike. A closed-loop referral system is a process that ensures the patient's needs are met by tracking the referral from initiation to completion, and then following up to ensure the patient's needs were addressed.

Building Trust Through Respect and Inclusion

For SDOH screening to be successful, patients must feel safe disclosing sensitive information about their lives. This requires culturally competent communication, respect for individual dignity, and assurances that their data will be used to support — not penalize — them. Training clinical staff to ask questions with empathy and without bias is critical. Providing clear explanations about how social data will be used, stored, and shared helps build transparency and trust, especially among communities that have historically experienced discrimination in healthcare settings.

Measuring Impact on Health Equity

Beyond identifying needs, organizations must measure the impact of SDOH interventions on health outcomes and disparities. Key metrics might include :

Reduction in emergency department visits and avoidable hospitalizations among high-risk groups.
Improved management of chronic conditions in underserved communities.
Increased access to preventive care services.
Patient-reported improvements in social stability and overall well-being.

By tracking these outcomes over time and stratifying the results by race, ethnicity, and other social factors, organizations can demonstrate progress and adjust their strategies to maximize the impact on equity.

Overcoming Challenges in Implementation

While integrating SDOH screening offers great promise, it also presents challenges :

Workflow integration : Ensuring screenings do not overburden clinicians or disrupt care delivery.
Data privacy and consent : Safeguarding sensitive social data and securing informed consent.
Resource limitations : Addressing social needs requires robust referral networks and sufficient community resources, which may not always be readily available.
Sustained funding : Equity initiatives often require long-term investment and support from leadership, payers, and policy makers

Addressing these challenges requires a combination of strategic planning, including developing clear workflows and communication strategies, providing continuous staff training on SDOH and cultural competence, fostering community collaboration to ensure resources are available, and committed leadership to drive the initiative forward.

A Path Forward: Integrating Equity Into the Core of Healthcare

As healthcare systems continue to evolve, embedding health equity as a core value rather than an ancillary goal is essential. Using SDOH screening as a foundation, organizations can transform the way care is delivered, ensuring it is both equitable and comprehensive. Investing in SDOH screening and community partnerships supports not only better health outcomes for individuals but also healthier, more resilient communities. By prioritizing equity, healthcare organizations fulfill their mission to serve all people fairly and compassionately, ultimately creating a stronger and more just healthcare system for future generations.

Conclusion

Embracing SDOH screening as a tool to support health equity initiatives is not just a strategy, but a transformative approach to achieving health equity. It empowers healthcare systems to move beyond treating illness and towards addressing the social determinants of health that shape health outcomes, inspiring a new way of thinking and acting in the healthcare field. By integrating screening into everyday care, analyzing and acting on data, partnering with community organizations, and centering trust and transparency, healthcare leaders play a pivotal role in making tangible progress toward closing health gaps and improving lives. This responsibility empowers them to drive change and make a real difference in their communities. For forward-thinking organizations committed to justice, inclusion, and measurable impact, SDOH screening represents a crucial tool on the path to achieving accurate health equity. By aligning with these values, healthcare providers and policymakers can ensure that their work is not just practical, but also ethical and inclusive.

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