SDOH Data Exchange: A Simple Guide for Clinics and Care Teams
Social needs, such as food access, housing safety, transportation issues, and financial stress, affect most patient outcomes. Clinics collect this information every day through screenings and conversations. But collecting it is not enough.
If SDOH data remains trapped in a single system or department, care teams cannot act quickly. SDOH data exchange solves this problem by safely moving social needs information across providers, systems, and community partners so patients receive the right help at the right time.
Why SDOH Data Exchange Matters
Understanding a patient’s social context is essential for modern care. When SDOH data is shared across teams, workflows become faster, risks are identified earlier, and patients receive more complete support.
Why data exchange is essential:
- Gives teams a complete picture of the patient: When social and medical data appear together, care teams understand why a patient may miss visits or struggle with treatment plans.
- Prevents repeated questioning: Patients do not have to re-explain their challenges at every visit because the information follows them across systems.
- Speeds up access to support: Community partners can act immediately when they receive clear, complete information.
- Strengthens care coordination for complex patients: Shared data makes it easier to prioritize high-risk individuals in chronic care, behavioral health, and care management programs.
- Improves outcomes: Addressing food, housing, or transportation gaps early improves long-term health and reduces avoidable issues.
Where SDOH Data Comes From
Clinics collect social needs data in many ways. Each source adds valuable context, helping care teams understand what support is needed.
Primary sources of SDOH data:
- Intake forms: These capture early signs of food insecurity, unsafe housing, or transportation barriers during the first patient touchpoint.
- Standard screeners (PRAPARE, AHC HRSN): These tools ask validated, structured questions to identify social challenges accurately.
- Care manager assessments: Detailed conversations reveal deeper issues a patient may not share during a short provider visit.
- Telehealth visits: Virtual appointments make it easier for patients to discuss sensitive social concerns from home.
- Community partner updates: Organizations such as food banks and housing agencies share referral outcomes, helping clinics track progress.
- Automated digital surveys: Routine check-ins identify new risks between appointments, giving clinicians a fuller picture of patient needs.
How SDOH Data Is Shared Across Teams
SDOH data must move smoothly across departments, systems, and partner organizations. Each exchange supports faster action and better coordination.
Common ways SDOH data is shared:
- Within the clinic team, Providers flag social risks during a visit, and care managers receive instant alerts to follow up the same day.
- Between departments: Nurses may notice medication or transportation issues during vitals; this information is shared with case managers for follow-up.
- Between clinics and community partners: Digital referrals send clear service requests to food, housing, or financial assistance programs. Partners update status (received, in progress, completed) so nothing is missed.
- Across care networks: Hospitals, FQHCs, and ACO partners share risk information through secure exchanges, facilitating coordination.
- Between systems (EHR → platforms): Data flows from the EHR into care coordination platforms or HIEs, allowing authorized users to see updated social information.
Standards That Enable Safe and Accurate SDOH Data Exchange
To share SDOH data safely and consistently, healthcare systems use established technical standards. These ensure information stays accurate as it moves between platforms.
Key standards include:
- FHIR SDOH profiles: Provide a standard structure for screening questions, patient responses, assessments, and referrals.
- Closed-loop referral standards: Track every step of a referral—sending, accepting, following up, and completing so no patient falls through the cracks.
- HIE integration rules: Support secure regional record sharing so hospitals and clinics can access consistent patient data.
Privacy and Compliance Requirements (HIPAA/PHI)
SDOH data often includes personal hardships such as homelessness, hunger, or financial stress. Clinics must protect this sensitive information with strong privacy controls.
Required protections include:
- Role-based access: Limits social needs information to staff who need it for patient care, reducing privacy risks.
- Encrypted data transfer: Ensures all SDOH data moves through secure channels to protect patient identity.
- Consent tracking: Patients must understand what data is collected, why it is used, and which organizations are involved.
- Audit logs: Every access, referral, or update is recorded to comply with HIPAA and internal policies.
Common Challenges Clinics Face with SDOH Data
Many clinics want to share social needs data effectively but struggle with disconnected tools, manual processes, and limited visibility.
Frequent issues include:
- SDOH data stuck inside the EHR: Care managers and partners cannot act because the information is not shared outside the visit.
- Manual or paper-based referrals: These lead to delays, missed follow-ups, and lost cases.
- No visibility from partner organizations: Clinics cannot confirm whether a referral was accepted or completed.
- Different systems using different formats: Without standardized data models, sharing becomes inconsistent and time-consuming.
What Good SDOH Data Exchange Looks Like
A robust SDOH data exchange workflow enables fast, safe, and actionable sharing. When done well, it improves communication across teams and delivers timely patient care.
Signs of an effective SDOH exchange system:
- A single social needs record: All screenings, referrals, updates, and case notes appear in one unified view.
- Real-time alerts: Care teams receive notifications when new risks are reported, supporting early intervention.
- Clear referral tracking: Every referral shows a precise status sent, received, in progress, completed—so cases do not get lost.
- Automated routing: High-risk patients are automatically routed to care managers without manual sorting.
- Easy partner communication: Community partners can update referrals simply and quickly, making collaboration smoother.
Final Thought
SDOH data exchange is a critical part of whole-person care. When clinics share social-needs information clearly and securely, teams respond faster, coordinate better, and support patients more effectively.
If you’re responsible for shaping care processes, now is the right moment to examine how SDOH data moves across your system and where clearer, more seamless exchange could strengthen outcomes, reduce gaps, and improve the overall care experience.
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