As a physician, your goal is to improve patient outcomes—but are clinical interventions enough? Health equity ensures everyone has the opportunity to achieve optimal health, regardless of social or economic circumstances. Central to achieving health equity is addressing social determinants of health (SDOH)—the non-medical factors that influence well-being. These determinants include access to healthcare, housing, education, employment, transportation, and nutritious food. Research suggests that up to 80% of health outcomes are shaped by these factors, emphasizing the need to go beyond clinical care and focus on value-based care and population health management.

Why Physicians Should Address SDOH in Clinical Practice

For many physicians, the impact of SDOH shows up in missed appointments, poor medication adherence, and high rates of chronic illness among certain patient groups. Understanding these underlying social factors helps you go beyond symptom management and create personalized care plans that prevent costly complications. Addressing SDOH is not just an ethical imperative—it also improves clinical outcomes, boosts patient satisfaction, and reduces unnecessary healthcare utilization, such as emergency room visits or hospital readmissions. 

Value-based care models are increasingly becoming the standard in healthcare, shifting the focus from treatment volume to treatment outcomes. This makes it essential for physicians to integrate SDOH data into their practice to meet quality benchmarks, achieve better outcomes, and avoid financial penalties associated with avoidable readmissions. 

What are SDOH?

SDOH encompass the social, economic, and environmental conditions in which people live, work, and age. These determinants profoundly influence an individual’s ability to access healthcare, secure stable employment, and live in a safe environment. For example, individuals in underserved communities might struggle with access to healthy food or reliable transportation, resulting in delayed care and worse health outcomes. 

The World Health Organization (WHO) identifies five core categories of SDOH: 

1. Economic Stability: Employment, income, and financial security. 

2. Education Access and Quality: Literacy levels, access to schools, and health education programs. 

3. Healthcare Access and Quality: Availability of healthcare facilities and health insurance coverage. 

4. Neighborhood and Built Environment: Housing conditions, access to transportation, and neighborhood safety. 

5. Social and Community Context: Social support networks and exposure to discrimination or social exclusion. 

Each of these categories influences health outcomes. The greater the access to stable jobs, quality education, and healthcare services, the healthier the population will be. When these factors are lacking, health disparities emerge. 

The Impact of SDOH on Health Inequities

Health disparities arise when certain populations lack access to the resources, they need for good health. The CDC highlights that marginalized groups—such as racial minorities, low-income households, and rural populations—often experience higher rates of chronic conditions like heart disease and diabetes. These populations are also more likely to face barriers to healthcare access, such as lack of insurance or transportation. 

Food insecurity is a critical example of how SDOH influence health. People living in food deserts—areas with limited access to affordable, nutritious food—have higher rates of obesity and diabetes. Similarly, individuals living in unstable housing conditions are at greater risk for mental health issues and infectious diseases. Healthcare disparities not only affect individuals but also place a significant burden on healthcare systems through preventable hospital admissions and emergency care visits. 

How Healthcare Providers Can Address SDOH

Healthcare providers are adopting SDOH screening tools to identify social challenges—like transportation or housing issues—that hinder care. These tools connect patients with social services to address their needs. 

Building community partnerships with housing authorities, food banks, and transportation networks closes care gaps. For example, partnering with transportation services ensures patients can attend follow-ups. 

Effective care coordination between providers, social workers, and community organizations ensures seamless care, improving chronic disease management, reducing ER visits, and boosting patient satisfaction. 

Leveraging Digital Solutions to Promote Health Equity

Technology plays a pivotal role in supporting healthcare providers as they work to address SDOH. Predictive analytics in healthcare enable providers to identify at-risk populations and intervene early, reducing the likelihood of health crises. For example, predictive models can flag patients with unmet social needs who are at risk for hospital readmission, allowing providers to take proactive measures. 

Remote patient monitoring (RPM) is another tool that promotes proactive care delivery. RPM allows healthcare providers to track patients with chronic conditions from home, reducing the need for frequent in-person visits. This is especially beneficial for individuals living in rural or underserved areas who face transportation barriers. 

The integration of SDOH data into clinical workflows gives providers a comprehensive view of their patients’ circumstances. Embedding social data into electronic health records (EHRs) ensures that providers can design care plans that address both medical conditions and social needs, leading to better long-term health outcomes. 

Shaping the Future of Health Equity

Creating lasting health equity takes ongoing teamwork between healthcare providers, community organizations, and policymakers. Instead of just treating illness after it happens, healthcare providers need to focus on prevention by using population health management strategies. Building community partnerships and coordinating care are key to overcoming social barriers that keep people from getting the care they need on time. 

A shift toward value-based care is essential in advancing health equity. By focusing on outcomes rather than the volume of services provided, value-based care models incentivize providers to address SDOH and improve the well-being of their patient populations. Healthcare organizations that adopt predictive analytics in healthcare and remote patient monitoring tools will be better positioned to deliver proactive care and reduce health disparities. 

Moving Forward: A Collective Effort Toward Health Equity 

MDLand integrates health equity and SDOH directly into its iClinic® EHR system, empowering healthcare providers to create personalized care plans that address both medical and social needs. This embeds SDOH and health-related social needs (HRSN) screenings directly into patient profiles, ensuring that social and physical health factors are addressed holistically. It facilitates comprehensive care planning, improves patient engagement, and enhances the ability to coordinate follow-ups and referrals. 

Learn more about iClinic® innovative tools to advance health equity by scheduling a demo

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