Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations

With the recognition that social determinants of health (SDOH) can account for up to 40 percent of individual health outcomes, particularly among low-income populations, their providers are increasingly focused on strategies to address patients’ unmet social needs (e.g., food insecurity, housing, transportation, etc.). This report examines how organizations participating in Transforming Complex Care (TCC), a multi-site national initiative funded by RWJF, are assessing and addressing SDOH for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care, including: (1) selecting and implementing SDOH assessment tools; (2) collecting patient-level information related to SDOH; (3) creating workflows to track and address patient needs; and (4) identifying social service resources and tracking referrals.