Social Determinants of Health

Social Determinants of Health
Taking Action  
Screening Tool  
Providing Patients with Resources
Health Disparities and Harris County Statistics  
Additional Resources
Cultural Awareness webpage

What are Social Determinants of Health?

Social determinants of health (SDOH) are defined to be the conditions in which people are born, grow, live, work, and age that contribute up to 80% of individual health outcomes. SDOHs have a major impact on people’s health, well-being, and quality of life, and present challenges for patients and their ability to receive care.

Disruptions at work, school, home, and in society can cause additional problems for the patient, negatively affecting their state of mind and physical health. For instance, there may be barriers that prevent patients from following through on their care plans and attend appointments, such as a recent job loss or the lack of transportation. Additionally, if they are facing health literacy issues, patients can find it difficult to understand prescribed medications and follow the plan of care.

In the current situation of COVID-19, millions of individuals have lost employer-sponsored health insurance and a source of income. This has caused them to be unable to afford treatment and medication.

SDOHs also contribute to wide health disparities and inequities. For example, people who do not have access to grocery stores with healthy foods are less likely to have good nutrition. This raises their risk of health conditions like heart disease, diabetes, and obesity — and even could lower one’s life expectancy.

For more information about how social determinants impact the health of a patient and for examples of resources, refer to the "Five Categories of SDOH and Resources” document.

Importance of Taking Action

To address a patient’s health issues, it is vital for physicians to gain a comprehensive understanding of what factors may be contributing or causing the patient’s condition. This promotes the idea of “whole-person care", ensuring that patients are satisfied and are receiving the best care possible.

Because healthcare has already started its transition to value-based care, identifying and addressing SDOHs will only improve health outcomes due to the more comprehensive health diagnosis and associated treatment and intervention.

To identify and address SDOHs, practices can follow these steps:

  1. Select a SDOH Screening Tool relevant to the patient population to utilize in the practice.
  2. Implement screening tool to understand prevalent socioeconomic needs of patients.
  3. Connect patients with contacts, resources, and referrals in the community to help them feel less distressed, feel supported, and improve their health outcomes. Establish and utilize existing community partnerships with organizations and professionals, such as community health centers, food banks, support groups, and other resources.

Step 1: Select a Screening Tool

Practices can use screening tools to identify SDOHs and equip patients with resources that they need.

As there is not a standardized screening tool used by all health systems today, questions can be selected from one or more screening tools. Since the goal is to help the patient and guide them, it is imperative practices select social determinants for which the practice can provide resources or referrals. Overall, the questionnaire should be short, simple, and meaningful.

View the following chart and peer-reviewed screening tools to see which questions and format may be relevant to your patient population:





Step 2: Implement Screening Tool to Identify SDOHs

Integrating SDOHs tools in the current workflow will allow patients to be treated in a more holistic manner. When deciding on the screening process, it is important to consider:

  • Who will be screened? 
  • Who will administer the screening tool, or will it be self-administered? 
  • When and where it will be administered?
  • Will the screening tool be administered on paper or electronically?
  • How will this be documented? EMR or paper?

Refer to the following guides to see examples of how screening tools were implemented:


Step 3: Provide Patients with Resources and Contacts to Address SDOHs

Based on the screening tool results, have a conversation with patients about whether they want assistance with these needs and how they can be better assisted. It is important to determine an action plan and follow-up with patients.

Practices can provide patients with the following resources:

  • Online or printed list of organizations in the community, contact information for financial assistance programs, support services, and/or referrals. 
  • Staff, navigators, community health worker, or social workers at the practice can suggest resources and contacts on a case-by-case basis.
  • Utilize online interactive tools that connect patients to resources based on zip code and social determinant.
    • Neighborhood Navigator (American Academy of Family Physicians) – Example: If a Food Category is chosen, the options presented would be: Food Pantry, Emergency Food, Food Delivery, HelpPay for Food, free Meals, Nutrition Education, and Community Gardens. Once one of these options is selected, a map and contact information is shown for the resources.
    • 211 Texas (Texas Health and Human Services) – search for available social services by zip code
    • United Way of Greater Houston – resource database
  • 2-1-1 Social Service hotline (Texas Health and Human Services Commission) – dial 2-1-1 for a free, anonymous, 24/7 telephone-based resource offering additional screening and warm referrals to social services.
  • Specific Social Determinant

Add SDOH to Enhance Evaluation and Management Codes

The American Medical Association’s 2021 Medical Decision Making (MDM) Table of Risk for outpatient/office evaluation and management (E/M) services is particularly innovative because it recognizes social determinants of health (SDOH) as a factor for determining the level of risk in MDM. Diagnosis or treatment significantly limited by SDOH is an example of a moderate risk of morbidity from additional diagnostic testing or treatment. To capture data on the social needs of patients, ICD-10-CM codes should be used as they identify non-medical factors that may influence a patient’s health status. Click here to view a list of ICD-10 codes.

Impact of Health Disparities on COVID-19

CMS data on COVID-19 highlighted how the pandemic has exacerbated health disparities and caused a disproportionate impact of COVID-19 on communities of color and lower income families. Race and income level were specifically highlighted as two contributors to the likelihood of hospitalization for the disease. These are risk markers for other underlying conditions that impact health – including socioeconomic status, level of education, access to health care, and increased exposure to the virus due to occupation (e.g., frontline, essential, and critical infrastructure workers). Click here to view graphs comparing these risk factors.

Statistics on Houston Health Disparities

  • 17% of black households do not have access to a vehicle, compared to 5% of whites and 8% of Hispanics. 
  • Obesity among adults has risen from 23.4% in 2002 to 31.0% (2017). Obesity is higher among black adults (47.3%), compared to whites (25.9%) and Hispanics (35.0%); and is higher among those with lower incomes and less education. Obesity among HISD high school students has risen to 20.4% (2017). 
  • 1 in 5 households reported severe housing problems, such as high housing costs, overcrowding, and the lack of a kitchen (2019). Also, there is a severe shortage of housing for low-income people. 
  • 1 in 3 youth aged 12-17 are overweight or obese. For adults, some communities have over 50% of adults classified as obese (2017).
  • Among Hispanics adults, 30.4% reported that they had not been able to see a doctor when they needed to, due to cost (2019). This population faces more difficulty in finding the funds to see a doctor, compared to other groups. 
  • Low-income residents are more likely to face barriers to healthy choices, such as longer distances to healthy food.

A common health disparity across Harris County is the prevalence of heart disease and obesity among communities of color and varying income levels. For example, 78.7% of Black and 75.7% of Hispanic residents were overweight or obese, compared to 64.4% of White residents and 68.0% of all Texans (2019). However, many of the risk factors for heart disease and obesity are modifiable and physicians can help address the underlying social determinants, such as diet, physical inactivity, mental health, and substance use.

For more statistics on health disparities in Houston, refer to these comprehensive resources from the Rice University Kinder Institute for Urban Research, Houston Health DepartmentCDC , and Harris County Public Health.

To see how physicians can deliver more culturally competent care and and address sociocultural factors, review the resources on the HCMS Cultural Awareness webpage.

Additional Resources