Social Drivers of Health and Health-Related Social Needs

Defining key terms:

  • Social drivers of health (SDOH): The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH refers to community-level factors. They are sometimes called “social determinants of health.” (Adapted from CDC Healthy People 2030)
     
  • Health-related social needs: Social and economic needs that individuals experience that affect their ability to maintain their health and well-being. They put individuals at risk for worse health outcomes and increased health care use. HRSN refers to individual-level factors such as financial instability, lack of access to healthy food, lack of access to affordable and stable housing and utilities, lack of access to health care, and lack of access to transportation. (Adapted from HHS)
     

  • Health disparities: Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health, health quality, or health outcomes experienced by disadvantaged populations. (Adapted from CDC)

     

  • Health equity: The attainment of the highest level of health achievable for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. (CMS)

Understanding Social Determinants of Health and Health-Related Social Needs

The way communities and individuals experience health and health care is not just based on access to medical services. It is also impacted by other factors that may support or create barriers to health and well-being.  At a community level, these factors are referred to as “social drivers of health” (SDOH) and may also be referred to as “social determinants of health.” Examples of SDOH include economic stability, access to quality education and health care, and the neighborhood and built environment.

The specific factors that impact individuals directly are called “health-related social needs” (HRSN). Examples of HRSN include lack of stable or affordable housing and utilities, financial strain, lack of access to healthy food, personal safety, and lack of access to transportation. SDOH and HRSN can coincide and overlap, for instance, in the case of a household with income below the federal poverty line (an individual-level HRSN) in an area with poor economic conditions (a community-level SDOH). Health providers can take steps to address HRSN by understanding the needs of their patients and referring them to community-based services.

SDOH and HRSN are what commonly lead to health disparities—that is, different health outcomes in different groups of people. Addressing SDOH and HRSN is an important component of efforts to overcome disparities and achieve health equity for individuals and communities.

The Impact of SDOH and HRSN on Health Outcomes

SDOH strongly influences a community’s health and life expectancy and also contributes to health disparities. They affect people before, during, and after they interact with a health care system.

Consider a neighborhood without any grocery stores that stock fresh foods. People living in these “food deserts” likely struggle with access to good nutrition, raising their risk of health conditions like heart disease, diabetes, and obesity. People who live in areas with higher levels of air pollution may be more likely to experience respiratory conditions like asthma, emphysema, and chronic obstructive pulmonary disease (COPD). In turn, the resulting health problems from these SDOH issues may contribute to lower life expectancy compared to people who have access to nutritious food and clean air.

Similarly, HRSN explains why individuals may experience different health outcomes. For example, people without financial stability may not be able to afford basic medical care—including prescription medications—and they may go without preventive visits to providers or delay seeking treatment for health issues. People without reliable transportation may not be able to keep their appointments with health care providers.

How the CMS Innovation Center Addresses SDOH and HRSN

There are many ways the health care system can address SDOH and HRSN to achieve better health outcomes for communities and individuals. Here are some of the ways in which Innovation Center pilot programs (known as models) test how to address SDOH and HRSN to improve patient experience with the goal of reducing health disparities:

  • Requiring model participants to provide screening for HRSN and referral to community resources and other social services to address individual needs 
  • Focusing on addressing HRSN to reduce disparities in certain areas, such as maternal health
  • Providing patients access to care navigators, community health workers, and other professionals who can connect patients with resources to meet their HRSN
  • Requiring model participants to develop plans for how they will achieve greater health equity

An Example of Care that Addresses SDOH and HRSN:

Roberta visits her neighborhood clinic, a Federally Qualified Health Center (FQHC) because she is experiencing shortness of breath and has blood pressure. Her intake paperwork includes a screening assessment for HRSN. It asks questions about her living situation, food security, transportation, utilities, safety, financial strain, employment, family and community support, and education.

Her answers indicate that she will have difficulty paying for blood pressure medication and may have trouble getting to the clinic on her own for regular checkups. After reviewing her HRSN assessment, a member of her care team meets with Roberta to better understand her needs, as well as to discuss the available resources in the community to address those needs. A care navigator at the health center finds that Roberta is eligible for a local nonprofit’s financial help program, which could cover some medication costs. The navigator collects all the needed information from Roberta, her doctor, and her pharmacist to enroll her in the program. Additionally, the navigator arranges transportation between Roberta’s home and the clinic with a local service for the aging. The navigator then follows up to make sure Roberta receives her medication and is able to follow her treatment plan.

Read Real-World Stories About Person-Centered Care That Addresses HRSN:

Additional Information

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