SDOH Challenges: Why Clinics Struggle to Address Social Needs in Daily Care
Social needs such as food access, housing stability, transportation, utilities, and financial strain directly shape how patients access care and follow treatment plans. Yet many clinics and FQHCs struggle to identify these needs consistently and respond in time. These issues aren’t caused by poor staff performance; they come from fragmented workflows, inconsistent data, and limited visibility across partners.
A clear SDOH framework helps teams detect needs early, reduce delays, and coordinate support more efficiently. This guide breaks down the most common challenges, how they impact day-to-day care, and what healthcare leaders can do to build reliable SDOH workflows.
Why Clinics Struggle With SDOH Workflows
1. Patients Miss Appointments Due to Everyday Barriers
Patients often want to follow their care plans but face real-life obstacles that prevent them from attending visits. Transportation problems, unpredictable work shifts, or childcare gaps can disrupt even routine check-ins.
Example : A patient misses two blood pressure appointments because her shift time changed, and she has no one to watch her child.
2. Chronic Conditions Become Harder to Manage Without Basic Needs
Long-term clinical goals break down when patients don't have the basics: safe homes, food, transportation, or stable utilities. These gaps make it difficult to maintain diet plans, medication schedules, and follow-up visits.
Example: A patient's diabetes worsens because their refrigerator is inconsistent, making insulin storage unsafe.
3. Staff Lose Time Making Manual Calls to Community Partners
Care managers often call food banks, shelters, housing agencies, or mental health programs repeatedly to check availability or capacity. This slows down care and takes time away from patient support.
Example: A care manager calls a housing partner three times before learning they stopped accepting referrals weeks earlier.
4. Reporting Is Inconsistent When SDOH Data Is Scattered
Screenings completed on paper or in disconnected tools produce data gaps that affect UDS/HEDIS reporting, risk scoring, and care planning.
Example: A clinic discovers that 25% of transportation-need screenings were never entered into the EHR, leading to missed follow-up opportunities.
How SDOH Challenges Show Up in Daily Clinical Workflows
SDOH challenges often start small but create significant ripple effects in operations and patient care.
Step 1. Screening Challenges
Long or Disconnected Forms Lead to Missing Data
Patients skip questions when forms are too long or confusing. Staff must manually re-enter the information, creating delays and errors.
Example: A patient leaves most of the SDOH form blank because she was rushed during check-in.
Data Stored Outside the EHR Creates Blind Spots
SDOH details on paper, PDFs, or notes make it difficult for teams to track trends or provide timely support.
Example : A housing concern written on a sticky note never gets logged, leading to a missed intervention.
Step 2. Stratification Challenges
High-Risk Needs Aren't Clearly Flagged
Without a straightforward triage process, urgent needs get buried, and care teams miss early opportunities to intervene.
Lower-Risk Needs Get Lost in General Workload
Routine needs may not prompt timely follow-up, leading to delays that affect long-term care plans.
Step 3. Referral Challenges
Unpredictable Community Partner Capacity Creates Delays
Partners often change their availability, hours, or intake rules. Clinics send referrals without knowing whether the partner can accept them.
Example: A housing agency on hold for a month still receives referrals, leaving patients with no response.
Unclear Referral Steps Confuse Staff and Patients
When clinics lack a structured workflow, referrals become inconsistent, and patients receive incomplete instructions.
Step 4. Follow-Up Challenges
Manual Follow-Up Is Slow and Time-Consuming
Care managers spend hours calling community organizations to confirm updates that could otherwise be automated.
Example: A care manager calls multiple food banks just to find one with availability.
No Visibility Into Referral Status Causes Care Gaps
Clinics often do not know if a referral was accepted, declined, or ignored. Cases slip through gaps, and patients lose access to needed services.
Step 5. Outcome Challenges
Lack of Closed-Loop Documentation Weakens Reporting
When outcomes aren’t recorded, clinics cannot confirm whether support reached the patient or improved their condition.
Example: A utility assistance referral is marked “sent,” but the clinic never learns if the patient received help.
Value-Based Care Performance Suffers
Incomplete outcome data leads to weaker reports, inaccurate risk scores, and missed opportunities for quality improvement.
Core SDOH Interventions and How They Ease Challenges
Food Support Programs
Food programs provide patients with consistent access to meals needed to support medication schedules and disease management. Weekly produce deliveries help patients follow diabetes plans more reliably.
Housing Stability Programs
Housing support provides safe, stable living conditions that reduce stress and prevent respiratory flare-ups. Mold cleanup can significantly reduce asthma attacks for children.
Transportation Assistance
Reliable rides prevent no-shows and maintain continuity of care. Pregnant patients benefit from scheduled NEMT rides for prenatal appointments.
Behavioral & Social Support
Emotional support improves follow-up consistency and treatment engagement. Support groups and CHW outreach help patients stay on track.
Financial & Utility Assistance
Reducing financial strain helps patients stabilize routines and follow their care plans. Utility relief helps patients safely store temperature-sensitive medications.
A Simple Table Summary of SDOH Challenges
| Challenge Area | Operational Issue | Impact on Care |
|---|---|---|
| Screening | Long or disconnected forms | Low completion rates, missing data |
| Data Capture | Scattered or manual entry | Poor visibility, unreliable records |
| Partner Coordination | No real-time updates | Delayed referrals, patient frustration |
| Follow-Up | Manual calls and emails | Slow workflows, high staff burden |
| Outcome Tracking | Missing documentation | Weak reporting, unclear patient results |
What Helps Clinics Overcome These Challenges
- Effective SDOH programs succeed because they follow simple, consistent workflows. When steps are standardized, staff know exactly how to screen, triage, and refer patients without confusion.
- Real-time updates from community partners keep clinics aware of capacity, reducing delays and helping teams route patients to programs that can actually accept them.
- Automated routing prevents cases from getting stuck. When a partner is full or unresponsive, the referral shifts to the next available provider, reducing downtime and manual labor.
- HIPAA-aligned data handling protects sensitive information about housing, finances, and safety, building trust and ensuring compliance.
- Clear, consistent outcome tracking shows whether patients received support, how quickly it was delivered, and whether their condition improved. This strengthens value-based care performance and helps clinics demonstrate real impact.
Impact on Care Delivery & Operations
1. Reduced No-Shows
When barriers like transportation or food insecurity are addressed early, patients are more likely to attend appointments and follow treatment plans.
Example: Transportation support reduces missed dialysis sessions.
2. Better Chronic Disease Control
Stable access to food, safe housing, and consistent utilities helps patients manage conditions like diabetes, hypertension, and asthma more effectively.
Example: Patients with access to fresh food maintain better blood sugar control.
3. Lower Staff Workload
Structured workflows reduce the time staff spend on manual tasks, such as making phone calls or updating spreadsheets. Care teams can focus more on patient support instead of chasing information.
Example: Automated referral updates save hours of follow-up each week.
4. Stronger Value-Based Care Performance
Accurate SDOH documentation improves UDS/HEDIS reporting, enhances risk scoring, and helps clinics demonstrate actual patient needs.
Example: Completing SDOH data increases the accuracy of quality dashboards and reduces reporting errors.
Conclusion: A Simple Next Step for Healthcare Leaders
You do not need to overhaul your entire SDOH program at once. Start by improving one part of the workflow: screening, referrals, or follow-up. Strengthening even a single step can reduce delays, enhance patient engagement, and make everyday work easier for clinical teams.
If your organization wants support in building reliable SDOH structures, Pillar Healthcare coordination software by SocialRoots.ai provides frameworks designed for real-world clinical operations and community-based care.
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