Transforming care through social determinants of health

Social determinants of health (SDOH) — the conditions in which people are born, live, work, and age — account for up to 80% of health outcomes in the United States. A growing body of evidence from national organizations demonstrates that addressing SDOH is essential to improving population health, reducing preventable costs, and advancing health equity. As health care leaders increasingly recognize, clinical care alone cannot close persistent gaps in access, outcomes, or experience. To achieve sustainable improvement, organizations must integrate social needs into care delivery, analytics, and community partnerships — creating a more resilient, equitable, and cost-effective health care system.

Embedding SDOH interventions across health care services enhances outcomes, reduces avoidable utilization, and aligns with an expanding policy environment that prioritizes equity and whole-person care.

Why social determinants of health matter more than ever

SDOH significantly influence chronic disease prevalence, health care engagement, medication adherence, and hospitalization rates. Factors such as housing instability, food insecurity, lack of transportation, limited social support, and low health literacy shape patients’ daily lives and directly affect their ability to manage health conditions.

Health care organizations that proactively address SDOH consistently report better patient outcomes, fewer emergency department visits, and stronger regulatory performance. These improvements result from upstream investments that prevent downstream complications. Stable housing lowers emergency utilization, reliable transportation improves appointment adherence, and nutrition support strengthens chronic disease management. These interventions reduce long-term costs while improving quality of life.

National initiatives reinforce this approach. CMS’s Health-Related Social Needs (HRSN) Framework (2024) calls for standardized SDOH screening, referral tracking, and community partnerships across payer and provider models. Similarly, Healthy People 2030 identifies SDOH as central to improving national health outcomes and reducing disparities. Together, these frameworks signal a clear expectation: social needs must be addressed as part of routine care.

Policy evolution and growing accountability

While health care policy evolves, one constant remains: federal and state agencies continue to emphasize health equity, whole-person care, and value-based accountability. SDOH integration is increasingly embedded in performance expectations through disparity reporting, equity metrics, and targeted interventions for vulnerable populations.

Recent legislative and regulatory trends reinforce that outcomes-based accountability is accelerating regardless of political administration. Health plans and clinicians are expected not only to measure disparities but to demonstrate meaningful action to reduce them. As a result, SDOH is no longer a supplemental initiative — it is a strategic pillar of organizational planning, compliance, and long-term sustainability.

A core driver of value-based care

Value-based care (VBC) models reward organizations for improving outcomes while reducing unnecessary utilization—precisely the areas where SDOH interventions deliver measurable impact. Addressing barriers such as transportation, food insecurity, and unsafe housing lowers avoidable hospitalizations, improves chronic disease control, and enhances patient satisfaction.

VBC emphasizes prevention, care coordination, and engagement. Understanding a patient’s social context enables more personalized care plans and improves adherence to treatment recommendations. This approach aligns with U.S. Preventive Services Task Force (USPSTF) guidance, which emphasizes social needs screening for high-risk populations. Increasingly, national quality frameworks recognize SDOH as inseparable from high-quality care.

Practical insights from real-world SDOH programs

Real-world experience highlights both the challenges and opportunities of operationalizing SDOH initiatives:

Referrals alone are insufficient. Simply providing resource lists rarely leads to sustained engagement. Members need guidance, connection, and follow-up to successfully access services.

Transportation is a high-impact, modifiable barrier. Innovative solutions—such as rideshare partnerships, durable medical equipment coordination, and benefit education—frequently unlock access to essential care.

Community-based engagement drives results. Face-to-face outreach, peer counselors, and community health workers play a critical role in navigating complex social environments.

Local context matters. Cultural centers, senior centers, and informal community networks often connect members to underutilized but highly effective resources.

These lessons underscore the importance of flexible, human-centered approaches that reflect each member’s lived experience. Understanding mobility limitations, financial constraints, and cultural expectations directly informs successful SDOH strategy execution.

Helping organizations operationalize SDOH

To translate SDOH insight into measurable impact, organizations need integrated, scalable solutions:

Advanced SDOH and predictive analytics. Combining clinical data with social risk indicators to stratify populations, identify care gaps, and target high-risk members—improving care coordination and return on investment.

Community-based outreach and navigation. Multidisciplinary teams including community health workers, peer counselors, and navigators provide personalized support and connect members to housing, nutrition, transportation, utility assistance, and cultural resources.

Compliance-ready equity and quality reporting. Comprehensive programs support CMS, NCQA, and state-level requirements, including disparity reporting, HEDIS SDOH measures, and emerging equity benchmarks.

Value-based care enablement. For organizations transitioning to VBC models, integrating SDOH into clinical workflows, care coordination, and population health strategies is vital.

Scalable workforce and technology solutions. Digital platforms, curated resource databases, and omni-channel outreach models improve efficiency, engagement, and measurable outcomes.

Through these capabilities, organizations can convert SDOH insights into action while building sustainable operational advantage.

The foundation of future health system performance

Addressing social determinants of health is essential to transforming health care delivery and meeting modern expectations for equity, quality, and efficiency. The future of health system performance depends on enabling organizations to operationalize SDOH through data-driven strategies, community-based interventions, and compliance-ready infrastructure. By addressing the root causes of health rather than treating illness alone, health care systems can create a more equitable, effective, and sustainable future for all.

Lori Skinner Campbell, M.S.N., MBA, is vice president of quality and population health strategies in clinical practice at Sagility.