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Building a care team to address social determinants of health

A social determinants of health care team is multidisciplinary, with clinicians, social workers, and population health experts at the helm.

As healthcare organizations prioritize social determinants of health (SDOH) work, they’re building out care teams that can support patients’ social needs.

Indeed, in healthcare’s era of team-based care, there’s increasing recognition that SDOH work needs exactly that: a multidisciplinary team. By tapping stakeholders with varied fields of expertise, healthcare organizations can achieve the wraparound, whole person care that experts say will improve outcomes.

Below, we outline the key members of the SDOH care team. To be sure, the field of SDOH work is nascent, and this list is not exhaustive. As organizations refine their SDOH strategies, the composition of these SDOH care teams is likely to change.

Clinicians: physicians, nurses, and beyond

Clinicians, from medical doctors to pharmacists, play a big role in flagging SDOH that impact patient health and well-being. To that end, they are important for initiating SDOH programming.

Primary care physicians (PCPs)

Most healthcare experts recognize the primary care office as the best location for screening for and addressing social determinants of health. Patients tend to have long-standing relationships with their PCPs, meaning they feel trust with their PCPs and may be more comfortable discussing sensitive topics.

That patient-provider relationship, plus the responsibility PCPs have for orchestrating care coordination and whole-person health, primes them to address SDOH.

Primary care physicians (and the staff who work for them) are increasingly tasked with conducting SDOH screening, documenting results in the EHR, and initiating referrals. PCPs might also quarterback the teamwork between more community-facing healthcare professionals, like community health workers and social workers.

As noted above, many primary care physicians lean on the other providers in their clinics, such as nurses, to support this SDOH work.

Nurses & nurse practitioners

Although primary care physicians are often tapped to drive SDOH screening, in many cases, these tasks fall to nurses. That is because nurses tend to have more personal relationships with patients, which can engender trust and open communication lines about social drivers of health.

But nurses need the right tools to do this work.

According to the National Committee for Quality Assurance’s (NCQA’s) Social Determinants of Health Resource Guide, nurses need to know whom to screen, what factors to screen for, which questions to ask during SDOH screening, and how to implement SDOH screening.

Nurses and nurse practitioners themselves have also called for stronger training in screening for and addressing social determinants of health.

For example, nurses play a key role in patient education, which can parlay into supporting patients as they seek social services outside the clinic or hospital. Nurses need access to the right educational resources, plus simply have enough time, to address these concerns with patients.

Behavioral health specialists

Mental and behavioral healthcare providers are key in addressing SDOH because these factors affect mental and behavioral health.

For example, limited transportation access might impact a patient’s ability to seek mental health treatment or treatment for a substance use disorder. Meanwhile, food insecurity can impact a patient’s ability to manage medications for mental or behavioral health diagnoses and even prevent patients from focusing on their mental health.

To that end, it’s important for mental and behavioral health specialists to screen for SDOH as part of their clinical practice. When care coordination and interoperability are possible, it benefits both mental healthcare and primary care providers to exchange SDOH data.

But it’s not just the screening process that behavioral health specialists have an impact on, although their communication-driven and trusting relationships with patients prime them from screening.

Behavioral healthcare specialists also have the ability to treat patients for conditions that may arise from experiencing many SDOH, including anxiety or depression.


Pharmacists are important members of the patient care team because they often see patients within their communities and because they see patients frequently. Many patients have a lot of trust in their pharmacists, which puts pharmacists in a good position to screen for and address social determinants of health.

In fact, data has shown that the pharmacy is one of the ideal places to screen for SDOH. A 2022 study from the University of Buffalo found that pharmacy-based SDOH screening was acceptable to both patients and pharmacists, with 90 percent of pharmacists included in the study saying they felt comfortable completing screenings.

The study, which recounted two programs, one in New York and another in Missouri, showed that SDOH screening in the pharmacy was effective for flagging social drivers of health. Of the screenings completed in the pharmacy, workers flagged SDOH in 65 percent.

SDOH can also be addressed within the pharmacy.

In 2022, the Pharmacy Quality Alliance (PQA) outlined key ways pharmacists and pharmacies can do SDOH work. Some pharmacies are standing up community health clinics that deliver very basic forms of primary care and SDOH screening.

Others have worked to obtain donated medications from manufacturers to provide to patients experiencing financial barriers to care, PQA said.

Community & social workers

Beyond the clinical care team, healthcare organizations need to consider the team that will help patients obtain the social services they need to achieve health and well-being. Community health workers, social workers, and case managers can fill that gap.

Community health workers (CHWs)

Community health workers (CHWs) help bridge the gap from the SDOH screening to accessing a social service. They are unique because of their ties to the community the hospital or health system serves.

“Since CHWs typically reside in the community they serve, they have the unique ability to bring information where it is needed most,” according to the NIH. “They can reach community residents where they live, eat, play, work, and worship. CHWs are frontline agents of change, helping to reduce health disparities in underserved communities.”

CHWs are distinct from social workers or care coordinators because they come from the same communities as the population of focus. This puts CHWs in the position of bridging a gap between the patient and the healthcare system as a whole. CHWs are responsible for building patient trust and helping to connect patients with the healthcare system.

Social workers

Social workers can likewise be instrumental in assessing SDOH, providing counseling, and coordinating services. Social workers typically have a master’s degree and other forms of licensure, whereas CHWs do not.

Still, hospitals and health systems employ social workers to help bridge the gap between the healthcare organization and the community and social services a patient may need.

“They help patients understand their illness or condition and provide them with information about the resources available to them to cope with the emotional, financial, and social needs that arise with a diagnosis,” according to the Mayo Clinic College of Medicine and Science. “As an advocate for the patient, a social worker assures that patients’ emotional and social needs are met through their medical treatment.”

Medical social workers are baked into the fabric of the clinical care team and work with different healthcare providers and other allied health professionals to ensure a patient’s social needs are met alongside their medical needs.

Medical social workers can help coordinate care upon hospital discharge, coordinate care, provide some counseling or therapy during crisis, and connect patients to financial and other social resources.

Care coordinators & case managers

Care coordinators have historically been tasked with helping to coordinate the care patients get across the healthcare continuum. These allied medical professionals have typically focused on patients with complex healthcare needs, like cancer patients or patients managing multiple chronic conditions.

According to a sample care coordinator job listing template from the Centers for Disease Control & Prevention, care coordinators can help convene the entire care team and help navigate the patient.

“The Care Coordinator ensures patient navigation is implemented by managing client caseloads, conducting intake assessment and reassessment, and supervising Patient Navigators,” the sample job listing reads.

“Care Coordinators facilitate conversations between interdisciplinary Care Teams (including Patient Navigators, Care Coordinators, primary care physicians, and additional health care providers) and expedite client services referrals. The Care Coordinator is dedicated to providing support to staff in the field and is responsible for supervising Patient Navigators.”

As healthcare has continued to integrate SDOH work into overall patient care, care coordinators have been tasked with orchestrating access to social services as a part of their workflows. This means referring or directing patients to social services where needed.

Community-Based Organizations (CBOs)

CBOs are part of the boots-on-the-ground team that ultimately helps address SDOH. Healthcare organizations can form agreements with any number of CBOs that focus on different social needs.

For example, health systems might partner with a faith-based organization to hold a vaccine drive or spread public health messaging. A partnership with a food pantry could help address food insecurity.

CBOs are important parts of the SDOH care team because they meet patients where they are within their communities. This improves accessibility and trust.

Moreover, CBOs usually know exactly what patients need. For example, the food pantry in a mostly Hispanic neighborhood is more likely to have culturally relevant food options that the health system may not know to provide.

When forming partnerships with CBOs, hospitals and health systems need to consider how to balance the relationship and the power hierarchy. CBOs are experts on the resources they provide and the communities they serve, while health systems can provide the data and resources necessary to continue supporting the CBO.

Population health experts

Importantly, SDOH work is not entirely patient-facing. Healthcare organizations need a sophisticated data analytics system to manage the health and SDOH data they gather. That requires a team of data analytics and population health experts.

Data analysts are the number crunchers on the SDOH care team, meaning they collect, organize, stratify, and make sense of SDOH screening data. This allows analysts to identify trends in SDOH data. For example, the SDOH data team might flag higher rates of food insecurity among a certain age demographic.

From there, the health system’s population health team can design a program to address food insecurity tailored for younger patients.

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