Social Determinants of Health Screening & Navigation: Moving Beyond Acknowledgment to Systematic Action

Dr Neeraj Manikath , claude.ai

Abstract

Social determinants of health (SDOH) account for up to 80% of health outcomes, yet systematic screening and intervention remain underutilized in internal medicine practice. This review provides evidence-based strategies for implementing SDOH screening, building resource networks, and integrating navigation services into clinical workflows. We present practical tools, validated screening instruments, and actionable pearls for postgraduate physicians seeking to address the fundamental barriers that prevent patients from achieving optimal health outcomes.

Introduction: The Case for Systematic SDOH Intervention

A 58-year-old woman with poorly controlled type 2 diabetes presents for the fourth time this year with an HbA1c of 11.2%. Her medication list is appropriate, yet adherence remains elusive. Traditional medical education trains us to optimize pharmacotherapy, but what if the real problem is that she must choose between groceries and insulin each month?

This scenario illustrates a fundamental truth increasingly recognized in contemporary medicine: biological interventions fail when social conditions undermine them. The World Health Organization defines SDOH as "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life."[1] These include economic stability, education access, healthcare access, neighborhood environment, and social context.

Multiple studies demonstrate that SDOH account for 80% of health outcomes, dwarfing the impact of clinical care (10-20%) and genetics (10-15%).[2,3] Yet most clinical encounters focus exclusively on biomedical factors. This review addresses the implementation gap between acknowledging poverty and systematically addressing it.

Why Current Practice Falls Short

Traditional medical training emphasizes diagnosis and pharmacological management while relegating social factors to the realm of "unfortunate circumstances." This approach creates three critical failures:

First, the visibility gap. Without systematic screening, social needs remain invisible. Patients often don't volunteer information about food insecurity or housing instability during medical visits, viewing these as separate from "medical" concerns.[4]

Second, the intervention gap. Even when physicians recognize social needs, most lack structured pathways to address them. A study by Byhoff et al. found that while 85% of physicians acknowledged SDOH importance, only 22% had formal screening processes, and fewer than 15% had established referral mechanisms.[5]

Third, the outcomes gap. Patients with unmet social needs have significantly worse health outcomes across virtually every measured parameter. Food-insecure patients have 2.4 times higher odds of poor glycemic control.[6] Those lacking transportation miss 3.6 million medical appointments annually in the United States alone, resulting in disease progression and preventable complications.[7]

The Evidence Base for SDOH Screening

Systematic SDOH screening and intervention improve clinical outcomes. A landmark randomized trial by Berkowitz et al. demonstrated that patients receiving SDOH screening plus resource navigation had 30% improvement in food security and 15% improvement in medication adherence at six months compared to usual care.[8]

The Accountable Health Communities Study, the largest randomized trial of SDOH screening (involving over 3,000 patients), showed that screening combined with navigation services reduced emergency department visits by 8% and improved patient-reported health status.[9]

Importantly, screening alone without intervention provides no benefit and may cause harm by creating awareness without solutions. The key is coupling screening with navigation—connecting patients to existing community resources.

Practical Implementation Framework

Step 1: Select and Implement Validated Screening Tools

The PRAPARE Tool (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) is a 21-item standardized instrument developed by the National Association of Community Health Centers.[10] It covers five core SDOH domains:

• Economic stability (income, employment, insurance)
• Education access and quality
• Healthcare access and quality
• Neighborhood and built environment
• Social and community context

For time-constrained practice settings, evidence supports abbreviated screening. The "Core 2" questions demonstrate 85% sensitivity for detecting significant social needs:[11]

1. "In the past 12 months, have you worried that your food would run out before you got money to buy more?"
2. "In the past 12 months, has lack of reliable transportation kept you from medical appointments or getting medications?"

Pearl: Implement these two questions in your intake process immediately. They take 30 seconds to administer and identify patients requiring comprehensive screening.

ICD-10 Z-Codes provide a billing-compatible framework for documenting SDOH. Key codes include:

• Z59.0-Z59.9: Housing and economic circumstances
• Z60.0-Z60.9: Social environment problems
• Z62.0-Z62.9: Upbringing-related problems
• Z63.0-Z63.9: Family circumstances problems

Using Z-codes enables data tracking, quality improvement initiatives, and increasingly, value-based payment incentives tied to social risk adjustment.[12]

Oyster: Many electronic health records now have SDOH screening modules. If your institution doesn't, advocate for one. CMS has prioritized SDOH screening in quality metrics for 2024-2025.

Step 2: Build a Comprehensive Resource Directory

Screening without actionable resources creates frustration. Develop a curated directory of local resources across key domains:

Food Security:

• Local food banks and pantries (use FeedingAmerica.org/find-your-local-foodbank)
• SNAP (Supplemental Nutrition Assistance Program) enrollment assistance
• WIC programs for eligible patients
• Meals on Wheels for homebound patients

Medication Assistance:

• NeedyMeds.org: Database of over 14,000 patient assistance programs
• GoodRx.com: Pharmacy discount programs
• Pharmaceutical company patient assistance programs (most major medications have them)
• 340B discount pharmacy programs

Transportation:

• Local medical transportation services
• Medicaid non-emergency medical transportation (NEMT) benefits
• Ride-sharing partnerships (Lyft Healthcare, Uber Health)
• Public transit discount programs for disabled/low-income patients

Housing Support:

• Local housing authorities
• Homelessness prevention programs
• Utility assistance programs
• Temporary shelter resources

Financial Assistance:

• Hospital charity care programs
• Medical-legal partnerships for medical debt
• Free tax preparation services (VITA program)
• Financial counseling services

Hack: Create a one-page, periodically updated resource sheet specific to your geographic area. Include phone numbers, websites, and eligibility criteria. Make it available in examination rooms and waiting areas.

Pearl: Resources vary dramatically by locality. A national database means nothing if local programs have closed or changed eligibility. Designate someone (medical assistant, nurse, or administrator) to verify resources quarterly.

Step 3: Integrate Navigation Services

The most critical implementation step is incorporating a patient navigator—someone who bridges the gap between identification and resource connection. This is typically a social worker, community health worker, or care coordinator.

The Navigator Role:

• Conducting comprehensive SDOH assessments
• Connecting patients to appropriate resources
• Following up on referral completion
• Advocating for patients within complex systems
• Addressing barriers to resource access

Evidence shows that navigation services increase resource connection rates from 15% (physician referral alone) to 65-75% (navigator-assisted).[13] The navigator handles application paperwork, makes follow-up calls, addresses transportation barriers to appointments, and troubleshoots when initial attempts fail.

Models for Resource-Limited Settings:

If dedicated navigators aren't available, consider these alternatives:

1. Community Health Worker (CHW) Partnerships: Many federally qualified health centers employ CHWs who can serve multiple practices. Establish formal referral agreements.

2. Medical-Legal Partnerships: Many academic centers now have partnerships with legal aid organizations. Lawyers address eviction, disability benefits, insurance appeals—issues with massive health impacts that physicians can't resolve.

3. Technology-Enabled Navigation: Platforms like Aunt Bertha (findhelp.org) and 211 systems provide searchable databases with eligibility prescreening and digital referral capabilities.

4. Pharmacist Integration: Clinical pharmacists can identify medication cost barriers and navigate assistance programs during medication reconciliation.

Oyster: Don't assume you must solve everything. Your role is screening, brief intervention, and referral. Navigation is a distinct skill set. Attempting to be both physician and social worker leads to burnout without improving outcomes.

Workflow Integration: Making It Sustainable

The greatest barrier to SDOH screening isn't complexity—it's workflow disruption. Here's a practical integration strategy:

Pre-Visit (Medical Assistant/Intake Staff):

• Administer Core 2 screening questions
• Flag positive screens in EHR for physician review
• Provide resource handout to patients endorsing needs

During Visit (Physician):

• Acknowledge flagged SDOH concerns: "I see you've had difficulty getting to appointments. Let's address that."
• Perform brief focused assessment if needed
• Warm handoff to navigator when available, or schedule follow-up
• Document using Z-codes

Post-Visit (Navigator/Care Coordinator):

• Contact patient within 48 hours
• Conduct comprehensive assessment
• Connect to resources
• Follow up at 2 weeks and 30 days
• Report outcomes to care team

Time Investment: Core screening adds 30-60 seconds. Physician acknowledgment adds 1-2 minutes. This investment prevents hours spent managing preventable complications.

Measuring Success: Outcomes and Quality Metrics

Track these metrics to demonstrate impact:

1. Process Metrics:

   • Percentage of patients screened
   • Percentage of positive screens receiving referrals
   • Percentage of referrals successfully connected to resources

2. Clinical Metrics:

   • No-show rates (should decrease with transportation assistance)
   • Medication adherence rates
   • Disease-specific outcomes (HbA1c, blood pressure control)
   • Hospital readmission rates

3. Patient-Reported Metrics:

   • Patient satisfaction scores
   • Unmet social needs at 3-month follow-up

Pearl: Start with one SDOH domain (typically food or transportation), measure impact, then expand. Attempting comprehensive change simultaneously often leads to implementation failure.

Addressing Common Concerns

"I don't have time." Screening takes less time than managing diabetic ketoacidosis from insulin rationing or heart failure exacerbations from medication nonadherence. Prevention is efficient.

"That's not my job." Health is multifactorial. Ignoring social determinants while optimizing pharmacotherapy is like adjusting insulin doses while ignoring blood glucose measurements.

"Resources don't exist in my area." Resources exist in every community, though accessibility varies. Rural providers may need regional or telehealth-based navigation. The absence of perfect solutions doesn't justify abandoning systematic screening.

"Patients might be offended." Research consistently shows patients appreciate physicians asking about social needs.[14] Frame questions as part of comprehensive care: "We've learned that health is affected by many things beyond medical care. To help you best, I'd like to ask about other factors affecting your wellbeing."

Conclusion: The Path Forward

The patient mentioned in our introduction doesn't need another antihyperglycemic agent. She needs food security and medication assistance. Once those are addressed, her diabetes becomes manageable.

Moving from acknowledging SDOH to systematically addressing them requires three components: validated screening, curated resources, and navigation support. Begin with two screening questions, develop a local resource directory, and establish a referral pathway—even if initially informal.

The evidence is unequivocal: social determinants drive health outcomes more than any intervention in our prescription pads. As internists, we must expand our clinical model to address the conditions in which our patients live, not merely the diseases they develop within those conditions.

The Bottom Line: Start tomorrow. Add two SDOH questions to your intake. Identify one local resource for each domain. Connect patients who screen positive to assistance. Medicine has always been both science and humanism—SDOH screening is where they converge.

References

1. World Health Organization. Social determinants of health. Available at: https://www.who.int/health-topics/social-determinants-of-health

2. Hood CM, Gennuso KP, Swain GR, Catlin BB. County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. Am J Prev Med. 2016;50(2):129-135.

3. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21(2):78-93.

4. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-304.

5. Byhoff E, Cohen AJ, Hamati MC, Tatko J, Davis MM, Tipirneni R. Screening for Social Determinants of Health in Michigan Health Centers. J Am Board Fam Med. 2017;30(4):418-427.

6. Seligman HK, Jacobs EA, López A, Tschann J, Fernandez A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care. 2012;35(2):233-238.

7. Wallace R, Hughes-Cromwick P, Mull H, Khasnabis S. Access to health care and nonemergency medical transportation: two missing links. Transp Res Rec. 2005;1924(1):76-84.

8. Berkowitz SA, Hulberg AC, Standish S, Reznor G, Atlas SJ. Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management. JAMA Intern Med. 2017;177(2):244-252.

9. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable Health Communities—Addressing Social Needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8-11.

10. National Association of Community Health Centers. PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences. Available at: http://www.nachc.org/research-and-data/prapare/

11. Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. 2017.

12. Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting: Factors influencing health status and contact with health services (Z00-Z99). 2023.

13. De Marchis EH, Hessler D, Fichtenberg C, et al. Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers. Am J Prev Med. 2019;57(6 Suppl 1):S25-S37.

14. Gottlieb LM, Hessler D, Long D, et al. Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA Pediatr. 2016;170(11):e162521.