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Primary Care: On the Front Lines of Social Determinants of Health

July 16, 2021

Increasingly, primary care providers understand that social determinants of health (SDOH) impact their patients’ health, and recognize that when basic needs like food, housing, and safety remain unmet, patients cannot make the behavioral changes needed to improve and maintain their health.

For example, while it is routine for a physician to recommend dietary changes and an increase in physical exercise for a patient at risk of heart disease, it is easy to understand how it would be much harder for someone to follow these recommendations if they live in a neighborhood without safe places to exercise and without markets with fresh food options. Someone experiencing unemployment or homelessness may not have the necessary resources to consider these types of changes.  

SDOH are defined by the World Health Organization (WHO) as “the conditions in which people are born, grow, live, work and age.” Social risk factors are the SDOH associated with negative health outcomes. Social needs, on the other hand, reflect individuals’ perceptions of their needs based on the risk factors they have faced in their own lives. (1) While SDOH and social risk factors exist at the community level (e.g., food deserts or inadequate housing options), every individual has a unique set of social needs (e.g., food insecurity or homelessness).

Collecting information about social needs allows clinicians to develop treatment plans that are better tailored to their patients’ needs and priorities. Additionally, social needs information can be used to connect patients to needed community services and resources. In a 2011 survey, 4 out of every 5 primary health physicians agreed that addressing social needs is as important as addressing medical conditions. (2) However, many physicians also report that they do not feel confident addressing those needs in their clinical practice. (3)

A Tool to Help

For the EvidenceNOW Dissemination and Planning project for the Agency for Healthcare Research and Quality (AHRQ), Abt developed a tool titled Identifying and Addressing Social Needs in Primary Care Settings to help interested primary care practices integrate social needs screening into their clinical care. The tool includes:

  • Information about what type of social needs information to collect, and example tools and resources to help practices get started with screening
  • Discussion of various implementation approaches for practices to consider
  • Step-by-step information about how to connect patients with needed community resources
  • An overview of multiple ways practices can use the social needs information they collect, including to improve patient care, population health, practice quality, and even to maximize reimbursements.

The tool is disseminated through the Agency for Health Research and Quality’s (AHRQ) EvidenceNOW Tools for Change, a database of tools to help primary care practices improve care. It is also included in the Social Intervention Research & Evaluation Network’s (SIREN’s) evidence and resource library. AHRQ recently shared the tool with the House Energy and Commerce Committee as part of a briefing on their SDOH tools and resources.

While many primary care providers may have justifiable concerns about adding yet another activity to their already busy practices, research indicates that satisfaction increases for both patients and providers when providers make efforts to address patients’ social needs. (4)

Ultimately, caring for patients within the unique context of their lives allows for more patient-centered care, and increases the positive impact that healthcare can have on people’s health and lives.


  1. Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health. Washington, DC: The National Academies Press. National Academies of Sciences, Engineering, and Medicine. 2019. https://doi. org/10.17226/25467. Available from:
  2. Page-Reeves J, Kaufman W, Bleecker M, Norris J, McCalmont K, Ianakieva V, Ianakieva D, Kaufman A. Addressing social determinants of health in a clinic setting: The WellRx pilot in Albuquerque, New Mexico. J Am Board Fam Med. 2016 May-Jun;29(3):414-8. doi: 10.3122/jabfm.2016.03.150272. PMID: 27170801.Bottom of Form
  3. Gard LA, Cooper AJ, Youmans Q, Didwania A, Persell SD, Jean-Jacques M, Ravenna P, Goel MS, O'Brien MJ. Identifying and addressing social determinants of health in outpatient practice: Results of a program-wide survey of internal and family medicine residents. BMC Med Educ. 2020 Jan 16;20(1):18. doi: 10.1186/s12909-020-1931-1. PMID: 31948434; PMCID: PMC6966817.
  4. Bachrach B. Addressing patients’ social needs: an emerging business case for provider investment. Commonwealth Fund. 2014.
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