TOVA Community Health Public Health Commentary Excerpt
There is significant value in primary care providers completing social determinants of health needs assessments (SDOH) in their practices for patient needs evaluations. Social Determinants such as income, housing, food security, education, transportation, and access to healthcare can have a major impact on health outcomes. Traditional clinical care focuses primarily on diagnosing and treating medical conditions, but research consistently shows that social and environmental factors account for a much larger share of what influences overall health (Head, 2025). By assessing these social needs, providers gain a more comprehensive understanding of their patients’ lives outside of a medical setting, which allows for more personalized and effective care delivery. One of the key benefits of integrating SDOH assessments into primary care is the ability to identify and address barriers that interfere with health management. For example, patients who experience housing instability or food insecurity may struggle to follow treatment plans, not out of noncompliance, but because they lack the necessary resources for survival. When providers screen for these issues, they can connect patients with social workers or community organizations that provide targeted support for what holds them back. This process would allow patients to access assistance such as food pantries, housing aid, or even utility benefits; resources that will in turn improve their ability to maintain health.
Andermann (2016) highlights that physicians often avoid addressing social determinants of health issues because they feel helpless when faced with complex challenges their patients experience. However, she emphasizes that health professionals have a crucial role in identifying these factors and helping patients access community and social support services. By doing so, providers can bridge the gap between clinical care and the social realities influencing health outcomes. In addition, SDOH assessments help promote health equity by ensuring that care is tailored to each patient’s unique social context. Many individuals, particularly those from marginalized or low-income communities, face systemic barriers that impact their access to care and overall health. When providers are aware of and understand these factors, they can create more realistic and sustainable care plans that coincide with a patient’s financial or social limitations.
As part of an exploration of the social determinants of health, a needs assessment was conducted with a professor at Delaware State University (DSU) who lives with a neuromuscular disorder that causes weakness, stiffness, and pain, which limits her upper arm mobility. Despite her condition, she continues to face insurance-related barriers in accessing medical devices that would significantly improve her functional abilities, such as dressing, cleaning, lifting, and conducting her research work with students on campus. One such arm lift elevation device, priced at $2,000.00, remains uncovered by her insurance plan, making it financially inaccessible. Her situation highlights the ongoing gap between medical necessity and insurance coverage, illustrating how unmet social and economic needs can hinder patient independence and quality of life, even for individuals with steady employment, insurance, and education.
In summary, incorporating SDOH needs assessments into primary care adds substantial value by allowing providers to identify social barriers, enhance patient care, promote health equity, and inform public health strategies. By recognizing and addressing the social and environmental factors that influence health, providers can deliver more holistic and compassionate care that meets patients where they are. These assessments not only uncover hidden barriers to treatment adherence but also empower clinicians to connect patients with vital community resources. As the healthcare system continues to shift toward value-based care, integrating SDOH needs assessments into routine practice is essential for improving outcomes, reducing disparities, and ultimately creating a more responsive healthcare environment.
Author: Chloe Lassiter, BS
Co-Author: Nina Anderson, DNP, Delaware State University Senior Research Fellow
TOVA Community Health
Primary Specialty Care
213 Greenhill Ave., Suite B Wilm, DE 19805 I 2 North Capital Ave., Dover, DE 19901
(302) 429-5870 ext. 120
www.tovacommunityhealth.org
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