It’s become increasingly clear that social conditions—things like literacy, housing, and food security—have a significant impact on one’s health. Known as the social determinants of health, many healthcare providers are wisely taking steps to address them. Yet as we explained in our last blog post, how providers incorporate these activities is critical. Because the best practices for addressing them are not yet understood, providers will find more success if they integrate the activities into their own services, where they’ll have more control over health outcomes.

For many providers, integration is a daunting task for a few reasons. One, there isn’t enough knowledge as to what programming efforts are the most effective. Since community and individual patient needs can vary so much, a lot of time, energy, and resources go into designing and implementing social strategies. And social strategies take a lot of money—money which many health providers are finding hard to secure. 

Given these challenges, providers like hospital systems find it difficult to figure out where they should start. Should they open a food pantry? What should they be screening for? What new expertise do hospitals need to develop in order to properly treat their patients?

Addressing social determinants in clinical practice

There is no single way for medical practices to adopt social determinants programming, and the correct approach will vary according to each providers’ circumstances and goals. But the good news is that integrating care of social determinants does not mean that providers need to suddenly become social workers. Integration is not an all-or-nothing model; there are different levels of integration that medical providers can adopt to address social determinants. The level of integration required for success may change, depending on community needs, provider capacities, and any number of other unique factors. 

The key is figuring which parts of social care must be integrated—or handled in-house—and which parts can be outsourced to others. To make a difference, hospitals do not need to become full-fledged social services providers, offering services like food pantries or housing for patients. There are a host of options short of these more intensive efforts. Below, we highlight some of the ways in which healthcare providers can integrate care to address the social needs of their patients. 


One of the quickest ways for healthcare providers to address social needs is through patient screening. While many health practices offer some form of social needs screening, a 2019 study found that only 24% of hospitals and 16% of physician practices screen for the top five key social needs known to heavily impact health outcomes. The hospitals and practices that perform the highest amount of screening are those that focus more on health outcomes as the metric of success—and are enticed to incorporate social determinant care into their practice as a way of improving outcomes. While this should be celebrated, unfortunately it’s often the case that screenings come  without coordinated follow-up To truly make a difference, providers must confirm that a patient who is flagged for specific social needs receives assistance. 

Facilitated community partnerships

Another way for healthcare providers to address social needs is by partnering with local community services. Rather than doing a complete handoff, the key here is for providers to form close partnerships with community supports, ensuring coordination between medical care and community services. By employing a patient navigator or coordinator to facilitate communication between parties, healthcare providers can ensure their patients receive critical services without themselves taking on work they are unequipped to provide. For example, CHW LEADS leverages a network of community health workers as both part of a patient’s care team, and as navigators through myriad social resources. 

On-site care solutions

For some healthcare clinics, especially federally qualified health clinics that typically serve under-resourced populations, there is a benefit to directly providing some services under their roof. This level of integration is, itself, a spectrum. Solutions can range from including community health experts on a patient’s care team, to providing jobs training and internet access, such as Oak Street Health does at their health clinics. A 2020 study found that clinicians were more likely to refer patients to a patient navigator for social needs if that patient navigator was on-site at the health clinic, rather than a remote navigator. 

I recently stumbled across a quote in a study on social determinants of health that read, “population health suffers when weak ties isolate medical care from social services.” In order to improve health outcomes across the board, health professionals need to not just acknowledge the close ties between the two, but begin to integrate the social aspect of care into their everyday practices.


  • Jessica Plante
    Jessica Plante