Social Determinants of Health | January 2023 | Clinical Corner

January 1, 2023

Social Determinants of Health (SDoH)


Social Determinants of Health (SDoH) are the nonmedical factors that influence health outcomes. They are “the conditions in which people are born, grow, live, work, and age that shape health.”


SDoH can be grouped into 5 domains:1

  1. Economic Stability
    1.  Help people earn steady incomes that allow them to meet their health needs.
    2. (e.g., employment, income, poverty).
  2. Education Access and Quality
    1. Increase educational opportunities and help children and adolescents do well in school.
    2. (e.g., quality of day care, schools, and adult education; literacy and high school graduation rates; English proficiency).
  3. Health Care Access and Quality
    1. Increase access to comprehensive, high-quality health care services.
    2. (e.g., access to high-quality, culturally and linguistically appropriate, and health literate care; as well as access to insurance, healthcare laws, and health promotion initiatives.
  4. Neighborhood and Built Environment
    1. Create neighborhoods and environments that promote health and safety.
    2. (e.g., housing, transportation, workplace safety, food availability, parks and other recreational facilities, environmental conditions, sufficiency of social services).
  5. Social and Community Context
    1. Increase social and community support.
    2. (e.g., demographics, social networks and supports; social cohesion; racial, ethnic, religious, and gender discrimination; community safety; criminal justice climate; civil participation).



  • Addressing differences in SDoH makes progress toward health equity, a state in which every person has the opportunity to attain their highest level of health.
  • SDoH have been shown to have a greater influence on health than either genetic factors or access to healthcare services.  For example, poverty is highly correlated with poorer health outcomes and higher risk of premature death.2
  • SDoH, including the effects of centuries of racism, are key drivers of health inequities within communities of color.
  • What we saw during this pandemic in the US was the exposure of the American healthcare model’s lack of attention to its most vulnerable populations: seniors, the chronically ill and underserved populations.



 Success depends on developing clear and measurable objectives. This effort starts with understanding a community’s demography, geography, and population health data to chart a path for improvement.3

  • On a broader level, the Accountable Health Communities Model deployed in 2017, by CMS, is engaging 31 organizations across the country to address a critical gap between clinical care and community services in the current healthcare delivery system.
    • This is being done by testing the process of systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services to see if it will impact healthcare costs and reduce healthcare utilization.
  • To address SDoH, practitioners need to take the following actions:4
    • Empower patients to make informed health decisions about their wellbeing.
    • Address individual need through appropriate screening and referral services.
    • Utilize digital innovations to modernize the delivery of services and utilize customer contact channels with seamless hand-offs between them, i.e., HIE and patient portals.
    • Develop cross-sector partnerships that address the health and social needs of patients.
  • Any member of a person's care team can collect SDoH data during any encounter. This includes the patient, social workers, managers, patient navigators, clinical staff, nurses, providers, and physicians.
    • Appropriate codes (e.g., Z codes) are used to document.
    • Modes of collecting data varies by your office or institution and Cerner integration is pending.
  • Any patient that requires a referral for SDoH can be referred to McLaren Physician Partners (MPP) Care Coordination for additional assistance, or through a Cerner EHR Referral.



Each Z-Code has sub-codes associated with it to further specify the type of Determinant

Each Z-Code must be accompanied by a CPT® code