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  • Writer's pictureJorge Petit

Healthcare's New Frontier: Addressing Social Determinants for Better Outcomes

SDOH Graphic

In recent years, there has been growing recognition of the importance of Social Determinants of Health (SDOH)[1] and Health-Related Social Needs (HRSN)[2] in the healthcare sector. These factors play a crucial role in many of the disparities in our health outcomes. Recent focus on addressing these issues can be seen in a number of new initiatives and policies, particularly those focusing on integrating SDOH/HRSN into healthcare models and practices.

Healthcare professionals are increasingly being required to understand and address SDOH/HRSN in their different settings with the aim of providing more comprehensive and effective care.

These developments mean a shift towards a more inclusive and holistic approach to healthcare and involves recognizing and addressing not just the clinical aspects of health but also the social, economic, and environmental factors that impact a person’s health and wellbeing.


This holistic approach can lead to better health outcomes, particularly for vulnerable populations, and potentially reduce healthcare costs by addressing the root causes of health disparities. The integration of SDOH/HRSN into healthcare practice is a crucial step towards a more equitable and effective healthcare system.

In 2022, the Department of Health and Human Services (HHS) published a report: Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts that highlights successful evidence-based strategies to address SDOH and health-related social needs. This report discusses the effectiveness of various strategies in reducing health barriers, improving health outcomes, and lowering healthcare costs. It also reviews current federal efforts to address SDOH and improve health conditions among Americans. Some of the findings include:

  • strong evidence of the benefits for “housing first” interventions that provide supportive housing to individuals with chronic health conditions including behavioral health conditions. Check out my blog on this topic: The Intersection of Homelessness and Health Equity: A Deeper Dive

  • efforts to improve food access through healthy food environments, public benefit programs, health care systems, health insurers, and evidence-based nutrition standards can lower health care costs and improve health outcomes.

  • non-emergency medical transportation has been shown to be cost-effective by increasing use of preventive and outpatient care and decreasing use of more expensive care.

  • multiple randomized trials show that cash payments to families and income support for low-income individuals with disabilities are associated with better health outcomes.

  • early childhood care and education are also associated with positive health outcomes.

  • some studies of care management and coordination using multi- disciplinary teams that support HRSNs show reduced total cost of care and improved health outcomes, but the evidence overall on these effects is mixed.

This past November 2023, the U.S. Department of Health and Human Services (HHS) released a Call To Action: Addressing Health-Related Social Needs in Communities Across the Nation, focused on integrating health and social care to improve overall health and wellbeing. It highlights the significance of SDOH and HRSNs in influencing health outcomes and encourages multi-sector collaboration and community partnerships to address these needs. The Call To Action emphasizes the role of community-based organizations in coordinating services across health care and social care sectors, as well as several other initiatives that address HRSNs, including:

  1. Community Care Hubs: These serve as backbone organizations coordinating services across health care and social sectors as well as streamlining access to care and addressing SDOH.

  2. Data-Sharing Systems: Emphasis on developing data-sharing platforms that integrate health and social care information to improve service delivery.

  3. Community Partnerships: Encourages forming partnerships with local organizations, healthcare providers, and other stakeholders to address community-specific needs effectively.

  4. Training and Workforce Development: Focuses on building a skilled workforce, including community health workers and peer support specialists, to address SDOH.

  5. Innovative Funding Models: Discusses new funding approaches, including value-based care, to support these initiatives.


Recently the Biden administration released a Social Determinants of Health Playbook, aiming to advance health equity. This playbook aims to serve as a launchpad for addressing SDOH and is not a final comprehensive strategy but a set of foundational strategies for public and private organizations to build upon. This comprehensive approach highlights the importance of collaboration among different sectors, including community-based organizations, healthcare systems, clinicians, payers, and public health department.  


Additionally, the Biden administration issued guidance to state Medicaid directors encouraging the incorporation of value-based strategies across their healthcare systems with the potential to address SDOH and reduce disparities within the health care system. This is expected to improve efficiency, quality of care, and health outcomes by addressing SDOH and disparities across the healthcare ecosystem by recognizing that factors like stable housing, nutritious food, quality education, and employment opportunities significantly impact wellbeing. For more on this and specifically its impact on children’s behavioral health, check out my blog post: Improving Children’s Behavioral Health through Medicaid and CHIP.


Just 2 days ago, NY State Governor Hochul announced that the Centers for Medicare & Medicaid Services (CMS) had approved New York State’s 1115 Waiver Amendment to advance health equity, reduce health disparities and strengthen access to primary and behavioral health care across the state.  Several of the approved initiatives are aimed at addressing HRSNs as well as supporting greater integration between primary care providers, community-based organizations, and behavioral health specialists.  All these new initiatives and policies clearly demonstrate that the integration of SDOH and HRSN are not just an added value but a necessity for a comprehensive and equitable healthcare system. These portend a paradigm shift in our approach to health and wellbeing and underscore the need for a healthcare model that goes beyond traditional clinical interventions to encompass the social, economic, and environmental factors that profoundly impact health outcomes.


By addressing the root causes of health disparities, such as poverty, lack of stable housing, inadequate nutrition, and limited access to quality education and employment opportunities, we can start to rectify these systemic inequities and, in the process, improve individual health outcomes and reduce overall healthcare costs. This approach requires a concerted effort across various sectors, including community-based organizations, healthcare systems, clinicians, payers, and public health departments, emphasizing the importance of collaboration, data sharing, and innovative funding models.


The road ahead involves navigating new policies, fostering multi-sector collaborations, and continually adapting to the evolving healthcare landscape. However, the ultimate goal remains clear: a healthcare system that not only treats illness but actively promotes health and wellbeing for all, regardless of social or economic status. As we continue to explore and implement these innovative approaches, we can all look forward to a future where health equity is not just an ideal, but a reality.


[1] SDOH refers to the conditions in which people are born, grow, live, work, and age, as well as the wider set of forces and systems shaping the conditions of daily life.

[2] HRSN are social and economic needs that individuals experience that affect their ability to maintain their health and well-being, such as employment, affordable and stable housing, healthy food, personal safety, transportation, and affordable utilities.

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