What Is SDoH and Why Does It Matter for Community-Based Organizations, Social Care, and Government

In healthcare and human services, there is a growing recognition that improving outcomes requires more than just clinical care. At the heart of this shift is a focus on Social Determinants of Health (SDoH)—the non-medical factors that influence health and quality of life.

For community-based organizations (CBOs), social care, and government agencies, understanding and addressing Social Determinants of Health (SDoH) is essential to advancing equity, improving public health, and building stronger communities.

What Is SDoH?

Social Determinants of Health (SDoH) are the conditions in which people are born, grow, live, work, and age. These factors shape not just individual health but also community well-being and healthcare outcomes.

According to the Centers for Disease Control and Prevention (CDC), the main domains of SDoH include:

• Economic Stability (income, employment, food security)
• Education Access and Quality
• Healthcare Access and Quality
• Neighborhood and Built Environment
• Social and Community Context

SDoH accounts for up to 80% of health outcomes, making them more influential than clinical care alone.

How SDoH Works in the Real World

SDoH operates at both individual and systemic levels. For instance :

• A person without stable housing may delay or avoid medical care
• Lack of access to healthy food increases the risk of chronic illness.
• Low-income families may struggle with transportation to the clinic.
• Discrimination or social isolation can negatively affect mental health.

These social and environmental challenges directly impact health risks, access to care, and long-term outcomes.

Why SDoH Matters for Community-Based Organizations and Social Care

CBOs and social care are at the forefront of addressing SDoH. They often serve vulnerable populations who face multiple barriers related to housing, food, mental health, employment, and access to services.

Here's why SDoH should be central to their mission :

1. It Aligns With Core Mission

Most social care and community-based organizations (CBOs) exist to improve lives and promote equity. SDoH provides a framework for identifying root causes of health disparities, not just symptoms.

2. Improves Program Outcomes

Programs are more effective when they consider the whole person. For example, job placement services are more effective when paired with childcare and transportation support.

3. Supports Funding and Accountability

Many funders now require measurable impact on social determinants of health (SDoH)- related outcomes. Having structured SDoH strategies improves reporting and transparency.

4. Facilitates Cross-Sector Collaboration

Addressing SDoH requires partnerships with healthcare, government, and other social care. CBOs that understand and speak the language of SDoH are better positioned to collaborate.

The Role of Government in Supporting SDoH

Local, state, and federal governments play a key role in advancing SDoH through :

• Policy Development : Laws and funding for affordable housing, public transit, Medicaid expansion, and food access
• Funding Allocation : Grants and support for social care working on social issues
• Data and Research : Public health data on disparities and SDoH metrics
• Program Coordination : Government agencies often partner with CBOs to deliver wraparound services

Government efforts must be aligned with community-level action, which is why public-private partnerships are critical in SDoH efforts.

The Connection Between SDoH and Social Referrals

To move from awareness to action, organizations need a way to connect people with the resources that address their social needs. That's where social referrals come in.

A social referral is the process of identifying a person's non-clinical needs and connecting them with a community resource or support service. For example :

• A Client screened for food insecurity may be referred to a local pantry.
• A person experiencing homelessness may be referred to housing support.
• A student with mental health needs may be referred to a counseling agency.

Social referrals operationalize SDoH. They bridge the gap between identifying social needs and addressing them through action.

Community Referrals and Community Health Centers

Community health centers, including Federally Qualified Health Centers (FQHCs), are increasingly incorporating Social Determinants of Health (SDoH) screening and referrals into their care delivery.

These centers:

• Serve low-income, uninsured, or underinsured populations.
• Often screen patients for SDoH using tools like PRAPARE.
• Partner with social care and social service agencies to offer referrals.

However, without proper tracking tools, referrals often go unmonitored, and outcomes remain unclear. That's where referral platforms and closed-loop systems become essential.

Why Managing Social Referrals Is Essential for SDoH Success

Organizations addressing SDoH cannot afford to rely on spreadsheets, emails, or manual logs. Here's why effective social referral management is necessary :

1. Closes the Loop

A referral isn't complete until the client receives the service. Platforms that track referral outcomes ensure follow-through and accountability.

2. Improves Client Outcomes

Timely, well-matched referrals increase the likelihood that a client gets help when needed, before situations worsen.

3. Reduces Duplication of Effort

Automated platforms prevent repeated referrals or gaps in service, improving overall system efficiency.

4. Enables Reporting and Data Insights

For funders, partners, and stakeholders, being able to show impact metrics tied to SDoH referrals is a significant advantage.

Why the United States Needs Better SDoH Infrastructure

The U.S. faces persistent health inequities rooted in social and economic conditions. Addressing these requires :

• Stronger integration of healthcare and social services
• Scalable, tech-enabled platforms to manage referrals
• Better alignment between public policy and community action
• Investment in community-based leadership and data systems

By focusing on Social Determinants of Health (SDoH) and streamlining referral processes, the U.S. can reduce emergency visits, lower healthcare costs, and improve overall population health.

SocialRoots.ai's GridSocial: Your SDoH Referral Management Platform

If your organization is serious about addressing Social Determinants of Health (SDoH), you need a modern, purpose-built solution to manage social referrals, track outcomes, and collaborate across agencies.

GridSocial by SocialRoots.ai is a leading social referral and request platform explicitly designed for CBOs, social care, community health centers, and government partners.

With GridSocial, you can :

• Centralize referral intake across channels.
• Match requests with the right service providers.
• Track progress, resolution, and feedback.
• Generate SDoH impact reports for funders and stakeholders.
• Close the loop with complete transparency.

GridSocial by SocialRoots.ai is the social referral management platform built for the real-world needs of CBOs, social care, and community health clinics. Whether you're tackling housing, food, mental health, or other SDoH challenges, GridSocial helps you intake, route, and resolve requests quickly and accurately. No more siloed systems or lost referrals—just real-time coordination, measurable impact, and scalable community care. Empower your organization to do more, serve better, and drive outcomes that matter. Choose GridSocial to turn social referrals into social impact.

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