Funder: Robert Wood Johnson Foundation

Author: Caitlin Thomas-Henkel and Meryl Schulman, Center for Health Care Strategies

October 2017 | Brief


Compared to other industrialized nations, the United States spends disproportionately less on social services, and more on health care. This is true despite evidence that social determinants of health (SDOH) — including income, educational attainment, employment status, and access to food and housing — affect an array of health outcomes, particularly among low-income populations. Individuals with unmet social needs are more likely to have difficulties self-managing chronic health conditions, have repeat “no-shows” to medical appointments, and be frequent emergency department users.

With this understanding, providers are increasingly focused on strategies to address patients’ unmet social needs. This brief examines how organizations participating in Transforming Complex Care, a multi-site national initiative funded by the Robert Wood Johnson Foundation, 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 community resources and tracking referrals.

Social Determinants of Health Assessment Tools

Many of the sites participating in Transforming Complex Care adapted existing or created new assessment tools in order to better capture patients’ social needs and barriers to care. Examples of these screening tools are available to download below: