What Is SDOH? A Simple Guide for Clinics and Care Teams
Social Determinants of Health (SDOH) are the non-medical factors that shape a person's health every day. They influence whether a patient can show up for care, follow a care plan, stay safe, or manage a chronic condition. For clinics, FQHCs, hospitals, and care teams, SDOH is now a key part of quality care, risk scoring, and operational performance.
1. What SDOH Really Means
SDOH includes the conditions in which people live, work, learn, and access support.
These factors often decide the "real-world" outcome of a care plan.
Common SDOH Factors and Why They Matter
- Food Access: A patient without a stable source of meals struggles to control diabetes or maintain weight.
- Safe Housing: Poor housing impacts safety, stress levels, and the ability to store medications.
- Transportation Access: Determines whether the patient can attend appointments or pick up prescriptions.
- Income Stability: Affects medication affordability and treatment adherence.
- Community Safety: Impacts mental health and limits outdoor activity or exercise.
- Social Support: Lack of family or community help leads to isolation and missed follow-ups.
2. The Five CMS / Gravity SDOH Domains
Healthcare uses five standard SDOH domains to guide screening and care planning.
- Economic Stability: Income, job security, and ability to afford care or daily needs.
Why it matters: Financial stress often leads to skipped visits and delayed treatment. - Education Access & Quality: Reading level and health literacy.
Why it matters: Patients may misunderstand instructions or medication labels. - Healthcare Access & Quality: Insurance, language support, provider availability.
Why it matters: A patient may want care but cannot reliably access it. - Neighborhood & Built Environment: Housing conditions, food deserts, pollution.
Why it matters: Unsafe or unstable living conditions increase health risks. - Social & Community Context: Stress, family support, discrimination, community ties.
Why it matters: Low support systems affect recovery and chronic care management.
3. Why SDOH Matters in Daily Clinical Workflows
SDOH is one of the strongest predictors of outcomes.
Most real barriers occur outside the clinic walls.
How SDOH Affects Healthcare
- Missed Appointments: Often caused by transport issues, work schedules, or childcare needs, not a lack of interest.
- Low Medication Adherence: Patients skip doses due to cost or inability to store medicines safely.
- Uncontrolled Chronic Conditions: Stress, food insecurity, and unstable housing disrupt care plans.
- More ED Visits: Patients without stable support often use emergency care for routine problems.
4. How Clinics Screen for SDOH
Healthcare teams use structured tools to identify social risks.
Standard Screening Tools and Their Purpose
- PRAPARE: Helps FQHCs (Federally Qualified Health Centers) measure social risks tied to health outcomes and UDS (Uniform Data System) reporting.
- AHC-HRSN (CMS): Standardized questions used across Medicare and Medicaid.
- State Medicaid SDOH Forms: Align screening with local reporting and reimbursement rules.
- Custom Triage Questions: Used in urgent care or care management calls to catch new risks.
Where Screening Happens
- Intake visits
- Annual Wellness Visits (AWVs)
- Post-ED or post-discharge calls
- Care coordination outreach
Example:
A patient with asthma misses check-ups. Screening reveals mold in their apartment.
This changes the care plan and triggers a housing support referral.
5. How SDOH Data Gets Documented (HIPAA + FHIR)
SDOH data includes PHI, so documentation must meet security and compliance standards.
How Clinics Document SDOH Safely
- ICD-10 Z-Codes: Add social risk factors into the medical record for care planning and billing.
- FHIR SDOH Profiles (Gravity Project): Allow structured and secure data exchange with EHRs.
- Role-Based Access Controls: Protect sensitive social data so only authorized staff can see it.
- EHR Structured Fields: Make SDOH data usable for analytics and referrals.
6. Addressing SDOH: What Clinics Actually Do
Once needs are identified, clinics move to intervention and follow-up.
Real Clinical Interventions and Why They Help
- Food Pantry or Meal Delivery: Supports diabetes and hypertension management through stable nutrition.
- Transportation Services: Reduces no-shows by ensuring patients can reach appointments.
- Housing or Utility Support Referrals: Creates safe living conditions for medication storage, post-op recovery, and chronic disease control.
- Social Work or Behavioral Health Support: Helps patients facing stress, trauma, or isolation.
- Community Resource Navigation: Connects patients with local organizations that can meet essential needs.
7. The Biggest Operational Challenges Clinics Face
SDOH programs often fail because workflows are manual and fragmented.
Common Barriers
- Data Silos: SDOH data sits in the EHR and never reaches community partners who provide help.
- Manual Tracking: Staff rely on spreadsheets or phone calls to check referral status.
- Referral Drop-Offs: Clinics cannot see if a referral was accepted, completed, or ignored.
- Low Patient Engagement: Paper forms and lengthy phone calls result in incomplete screenings.
- Limited Staff Time: Care teams are overwhelmed and cannot follow up on every need.
8. How Pillar Healthcare Software Supports SDOH Workflows
Platforms like Pillar Healthcare Software by SocialRoots.ai help clinics automate and scale SDOH operations.
Key Capabilities and How They Help
- Digital SDOH Screening: Patients complete forms via SMS or mobile, reducing staff time.
- Automated Referrals: Send needs to food, housing, transport, and social service partners instantly.
- Closed-Loop Tracking: See every referral step—from “sent” to “completed.”
- FHIR-Based Data Exchange: Keeps EHR data secure, structured, and compliant with Gravity standards.
- Team Dashboards: Give care managers a real-time view of caseloads and pending tasks.
- Integrated Communications: SMS, reminders, and updates increase patient response rates.
9. The Impact: Better Care, Better Operations
When SDOH workflows are organized and connected, clinics see:
- Reduced no-shows thanks to clear transport and follow-up support.
- Better chronic disease control through stable food, housing, and support systems.
- Less staff burden by eliminating spreadsheets and manual tracking.
- Faster care coordination because referrals are automatically forwarded.
- Transparent reporting for value-based care, Medicaid, and UDS.
SDOH becomes a practical, everyday part of care, not an extra task.
A Simple Next Step
If you're exploring how to strengthen SDOH workflows, start by reviewing where your current process slows down screening, referrals, or follow-up. Even one improvement can make care smoother for both patients and your team.
If you want support, Pillar by SocialRoots.ai makes it easier to screen, refer, and track SDOH needs without adding more work to your staff. It helps clinics automate routine steps while keeping PHI secure and workflows compliant.
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