How can you ensure the care team is aware of patient social determinants of health?

1 Screen for SDOH

The first step is to screen your patients for SDOH using validated tools or questions. You can do this during intake, assessment, or follow-up visits. Screening for SDOH can help you identify the barriers and needs that your patients face, and tailor your care plan accordingly. For example, you can ask your patients about their housing, food security, transportation, education, employment, and social support.

2 Document and share SDOH

The second step is to document and share your findings and recommendations with the rest of the care team, including physicians. You can use electronic health records, care coordination platforms, or other communication channels to record and transmit the SDOH information. This can help the care team to have a comprehensive and holistic view of the patient, and to collaborate on addressing the SDOH issues. For example, you can alert the physician if a patient has difficulty affording medications, or refer the patient to a social worker or community resource.

5 Evaluate and improve SDOH practices

The fifth step is to evaluate and improve your SDOH practices and outcomes. You can use data, feedback, and quality improvement methods to monitor and measure the impact of your SDOH interventions on your patients and the care team. You can also seek opportunities to learn and update your knowledge and skills on SDOH. For example, you can track your patients' progress and satisfaction, or enroll in continuing education or training on SDOH.

6 Collaborate with physicians on SDOH

The sixth and final step is to collaborate with physicians on SDOH. You can communicate effectively, respectfully, and professionally with the physicians on your care team, and share your insights and expertise on SDOH. You can also seek their input and guidance on SDOH issues, and work together to provide patient-centered and holistic care. For example, you can discuss with the physician how to modify the treatment plan based on the patient's SDOH, or how to coordinate referrals and follow-ups for SDOH services.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?