Social Determinants of Health: A Framework for CPHQ
Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. These factors significantly influence health outcomes and are increasingly recognized as essential considerations in healthcare quality measurement and improvement. CPHQ candidates should understand the SDOH framework and its implications for quality programs.
Categories of Social Determinants
The World Health Organization and Healthy People 2030 identify several categories of social determinants. Economic stability includes employment, income, food security, and housing stability. Education access and quality encompasses literacy, language, and early childhood education. Healthcare access and quality covers insurance status, provider availability, and cultural competency. Neighborhood and built environment includes housing quality, transportation, water and air quality, and access to healthy foods. Social and community context includes social support, community engagement, discrimination, and incarceration history.
Impact on Health Outcomes
Research consistently shows that social determinants account for a larger share of health outcomes than clinical care alone. Some estimates suggest that social and environmental factors influence 30 to 55 percent of health outcomes, while clinical care accounts for only 10 to 20 percent. Patients facing social challenges such as food insecurity, unstable housing, or transportation barriers are more likely to have uncontrolled chronic conditions, higher rates of emergency department use, and poorer outcomes after hospitalization.
SDOH and Quality Measurement
Social determinants create challenges for quality measurement. Providers serving populations with greater social needs may appear to perform worse on quality metrics, even when their clinical care is excellent. This raises important questions about whether and how to adjust quality measures for social risk factors. The National Quality Forum has recommended stratifying quality measures by social risk factors to identify disparities, rather than adjusting in ways that might set lower expectations for disadvantaged populations.
Screening and Documentation
Many healthcare organizations now screen patients for social needs using standardized tools. Common screening areas include food insecurity, housing instability, transportation barriers, and interpersonal violence. Screening results can be documented in the EHR using standardized codes (such as ICD-10 Z codes). Quality professionals should understand how SDOH data is captured and how it can be used to identify at-risk populations and target interventions.
Addressing SDOH in Quality Programs
Quality programs can address social determinants through community partnerships, referral networks to social services, and care coordination models that account for social needs. Quality professionals can advocate for SDOH screening, analyze the relationship between social factors and quality outcomes in their organizations, and support care redesign efforts that address social barriers to health. As the field evolves, understanding social determinants will become increasingly important for quality improvement professionals.