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How to Address Social Determinants of Health at Your Practice

Analysis  |  By Christopher Cheney  
   May 02, 2023

The main steps to addressing social determinants of health are collecting data from your patients and designing a referral process.

The Physicians Foundation has launched resources and guides for physician practices to address social determinants of health.

Social determinants of health, which The Physicians Foundation calls drivers of health, include five primary factors: food security, housing stability, transportation access, utilities access, and interpersonal safety. About 80% of health outcomes are believed to be directly influenced by drivers of health.

The Physicians Foundation has posted several drivers of health resources and guides on its website including Let's Take 5 to Address Drivers of Health, Let's Take 5 Conversation Starter, and Let's Take 5 Steps Implementation Guide.

Integrating drivers of health into a practice requires preparation, says Gary Price, MD, president of The Physicians Foundation. "It will require preparation because collecting this data in a sensitive way and in a way that works for the practice and for the patients is going to require buy-in by multiple members of the healthcare team. It is going to vary greatly by practice setting. In a hospital setting, the process will be somewhat different from what might work in a rural independent practice."

For the first time, physician practices will be able to report a drivers of health quality measure as part of the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). For the 2023 reporting period, the quality measure is the percent of patients who are screened for drivers of health.

To address drivers of health, an individual practice needs to identify what they want to do, Price says. "A reasonable goal would be to begin collecting data in a way that is consistent with the MIPS quality reporting measure. It would also be important for the practice to identify ways that they might refer patients who identify as having social needs. The practice needs to identify which members of the team will be key leaders in implementing referrals and where the work is going to be done in the practice workflow."

Selecting a drivers of health screening method

An initial step to addressing drivers of health is selecting a screening method, he says. "After assessing the practice's needs and outlining the goals, the practice then needs to design a screening process. The good news here is that many templates for validated screening tools already exist. We have links to those on the Take 5 webpage, and the practice can look at those and choose the ones that are best for their practice and their patients. Many electronic medical record systems already have these screening tools built in."

Practices should assign someone to lead the screening process and follow best practices for asking patients questions about drivers of health, Price says. "Basically, the best practices involve making sure the questions are asked in an appropriate atmosphere—the patients should consider the setting private and safe. You need to build rapport with the patients as the questions are asked. You need to make sure the questioner employs empathy. You need to offer an immediate next step—some strategy for the patient to address drivers of health."

Designing a referral process

Once a practice has selected a drivers of health screening method, a key next step is designing a referral process, he says. "The referral process has to be efficient. It has to be integrated into the practice workflow, so it does not add much more time and effort. We regard the referral process as a time-saver, where the barriers for our patients attaining good health are surmounted."

Referral processes are going to vary by practice and the communities in which the work is done, Price says. "This is going to require the practice reaching out for resources that are already present in the community. The referral process step is a point where practices need to know that this work is not something they can do on their own—they are going to have to reach out and gain access to the various community resources. … This is a local and regional process, and practices can look to their local medical societies, to community social resources, and to their hospital systems that have already developed referral patterns."

Once a need has been identified, then the referral has to be made efficiently but it also has to be made to a resource that can actually follow through and connect the patients with the information and resources they need, he says. "Built into that process needs to be some feedback, so that if a referral is made, we can quickly ascertain whether it has been effective or not. In the future, you will see quality measures that ask about the effectiveness of the referrals—were they followed up on? More importantly, were they successful?"

Prospects for addressing drivers of health

Many healthcare organizations have years of experience in collecting drivers of health data, Price says. "We know that in a research study that was done before the onset of COVID in JAMA that a great number of hospitals and even smaller practices were already collecting this data. Over 90% of hospitals were collecting all five of the drivers of health measures before COVID, and about 16% of practices were collecting this data. When you look at how they are doing with measuring just one driver of health, the majority of hospitals and practices were measuring at least one. So, this process will not be completely new to most practices, but to those for whom it is new, we have the resources at The Physicians Foundation."

The Physicians Foundation played an active role in establishing the MIPS drivers of health quality measure, and the organization is committed to helping physician practices address drivers of health, he says. "The foundation has been involved in research about the importance of drivers of health for many years. Just introducing the simple metric of how many of your patients you are actually asking the questions of has started an intense amount of interest in looking for solutions for these problems that impact our nation's health so greatly. This is an inflection point in drawing attention to how drivers of health impact our health and our health outcomes."

Related: Social Determinants of Health: Lead or Partner

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


The first step to addressing social determinants of health is collecting data from patients, and there are several existing validated tools for screening.

The next step is designing a referral process to connect patients with social needs to information and resources in the community.

In 2023, physician practices will be able to report a social determinants of health quality measure as part of the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

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