How providers can help patients with social determinants of health

With more research, it's clear that physical and mental health outcomes are directly linked to patients' social determinants of health (SDOH): where patients live, work, learn and play. Keep reading to learn more about the data found along with the growing number of initiatives at the national and state levels to address social determinants of health.

How social determinants of health affect patient outcomes

The American Hospital Association (AHA) found that every year 3.6 million individuals miss an appointment because they did not have access to transportation to that appointment. For so many patients, transportation is a clear barrier to accessing care whether it's being without a vehicle, not being able to afford transportation alternatives, or long distances to doctor's offices. At first glance, missing an occasional doctor's visit may not seem too harmful, but long-term, it can seriously compromise patients' delivery of care. Missing a scheduled appointment erases an opportunity for a provider to make a potential diagnosis, or in some cases, jeopardize follow-up care. Both of these outcomes bring an increase in costs to patients as the likelihood of more health complications arise. A study found that low-income people with co-occurring conditions spend much more on inpatient or emergency department care than higher-income people do ($363 vs. $101).

In addition, patients that face homelessness or housing insecurity are more likely to deprioritize their health as their primary focuses shifts to finding shelter, even though these individuals are more likely to have chronic health problems. Some of these include seizures, chronic obstructive pulmonary disease, arthritis and other musculoskeletal disorders. For some, social limitations force them to choose between health or food. According to Feeding America, 66 % of those Feeding America serves had to choose between food access and medical care.

Another supporting example comes from Cardinal Health Specialty Solutions, where 91% of recently surveyed oncologists strongly agree or agree that SDOH significantly impacts their cancer patients. Financial security stood out as the most significant barrier, followed by transportation access, health literacy, and social isolation. The majority of oncologists agreed to the following solutions that could help patients dealing with SDOH were:

  1. financial assistance
  2. assistance with transportation
  3. effective tools to improve patient understanding of disease and treatment

Nearly all of the respondents say that they or their staff talk to patients about SDOH occasionally, but time doesn't always allow for these conversations. 81% of respondents strongly agree or agree they are constrained in the amount of time spent assisting patients with social needs. For solutions, respondents looked to government organizations and non-profit organizations to create assistance programs to help bridge this gap to support patient outcomes impacted by SDOH. 90% of participating oncologists said pharmaceutical manufacturers could best support patients' social needs through copay assistance programs.

Provider awareness is essential

Physical and mental health outcomes are directly linked to patients' social determinants of health: socioeconomic status, social support network, physical environment, food security & access to clean water, health literacy & coverage, civic participation & discrimination. So, when providers know what socioeconomic factors patients face, they can help them find the right kind of resources such as food pantries, shelters, translators, or child-care services. One resource that supports this process is, previously known as Aunt Bertha. This is a social service database used to connect members to free and reduced-cost community services. Thousands of resources are available with options to apply, refer, share and track by simply entering your zip code. The platform and materials can be converted to over one hundred different languages.

How providers can use to help patients

SearchEnter any valid zip code to search for local resources. You can also search by clicking on the individual categories to view programs in the area.

ShareCommunity resources can be shared with members in multiple ways:

  • Verbal
  • Print
  • Text
  • Email

ConnectClick 'Next Steps' to view how to connect a member to the resource or agency. Options may include: Next Steps, Refer, Apply, Schedule. Follow the directions for the agency's preferred method. Choose 'Log a Referral' if you would like the referral information to be saved for that member under 'People I'm Helping.'

ReferralsIf the information found in Aunt Bertha won't immediately resolve a member's need, place a referral to a Social Care Manager for outreach.

SupportFor technical support, click the 'Support' tab in the platform. Sign up for Helper Training at

Resources from the CDC

The CDC has outlined several tools providers can put into action, including:

Visit for a complete list of resources.

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