Social Determinants of Health

This tip sheet lists Z codes that can help practices identify unmet needs and barriers of patients.

This article addresses how social determinants of health (SDOH), such as food and housing insecurity can directly increase the burden of other blood vessel diseases, such as heart disease and stroke. Exploring and understanding the relationship between peripheral artery disease (PAD) and negative social determinants of health (SDOH) in older Black adults could lead to earlier diagnoses.

This statement, released by the American Heart Association (AHA), highlights the need to include nonbiological factors and social determinants of health in assessments for cardiovascular disease risk.

The report provides a portrait of the health and well-being of older adults across the United States. The report covers social and economic factors, physical environment, clinical care, behaviors and health outcomes. It includes state-by-state summaries and county-level maps for risk of social isolation by state.

Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. This recording reviews the five domains of SDOH identified by the Centers for Medicare & Medicaid for hospitals to screen.

This list of ICD-10 Z codes can help Blue Cross Blue Shield of Texas and its insureds to better discover the unique, social needs of its members and help connect them with available resources.

This tool from the Centers for Medicare & Medicaid Services (CMS) can assist providers to see if systematically finding and dealing with the health-related social needs of Medicare and Medicaid beneficiaries has any effect on total health care costs and health outcomes.

More than half of adults living in the U.S. have limited reading skills, but most health materials are written at or above a 10th-grade level. To create health communications that are effective and easy for patients to understand, this fact sheet from the Center for Health Care Strategies provides recommendations for using plain language, simple design principles and clearly organized content.

This fact sheet from the Center for Health Care Strategies offers guidance for providers on how to engage patients effectively through clear, culturally competent conversation and interviewing techniques.

Data, such as these resources maintained Centers for Disease Control and Prevention (CDC), can be a catalyst for improving community health and well-being. Understanding data on social determinants of health, such as income, educational level, and employment, can help focus efforts to improve community health.

This website connects you to the Centers for Disease Control and Prevention (CDC) resources for social determinants of health (SDOH) data, research, tools for action, programs and policy. They may be used by people in public health, community organizations, research organizations, and health care systems to assess SDOH and improve community well-being.

This article explores how social determinants of health contribute to uncontrolled blood pressure among Black adults. One conclusion: addressing the structural racism that leads to this challege requires interventions at the individual, interpersonal and institutional levels.

When the Center for Medicare & Medicaid Innovation (Innovation Center) launched the Accountable Health Communities (AHC) Model in 2017, the intent was to test whether connecting Medicare and Medicaid beneficiaries to community resources and addressing health-related social needs (HRSNs) can improve health outcomes and reduce costs. This report provides an overview of findings from the Second Evaluation Report.

Community health workers (CHWs) can improve health outcomes for those in the populations they serve. This blog post explores how CHWs bridge gaps between health professionals and their patients’ communities.

Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. In 2024, the Centers for Medicare and Medicaid will require hospitals in the Inpatient Quality Reporting program to submit two new SDOH measures. This recording provides an overview of these new measures.

Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. This recording will discuss the categories of Z-codes and how they can be used to improve health care processes.

Z codes capture other factors influencing health and medical services, including social data for what goes on outside the hospital walls that may effect a patient's well-being. A medical coder’s part in this effort is to capture and report SDOH codes correctly so providers, health plans, the government and other entities can use this data to fund and manage populations for better health outcomes.

Tips and a sample script for engaging patients in screening for social determinants of health (SDOH) during the admissions process.

This resource from the Centers for Medicare & Medicaid (CMS) can help providers better understand the use of Z codes to improve the quality and collection of health equity data. Using social determinants of health, Z codes can enhance quality improvement activities, track factors that influence people’s health and provide further insight into existing health inequities.

The American Academy of Family Physicians created this handout to help care teams understand social determinants of health and how to develop a team-based care approach to identify specific patient needs and how to address those needs.

This article focuses on a "Health Affairs" study that found a link between food insecurity and missed workdays and overnight hospital stays among U.S. adults with diabetes.

This infographic from American Hospital Association data shows how hospitals are addressing social needs of their patients. In surveys, 87% of hospitals reported that their health systems screen some patients for social needs and that, on average, hospitals have 19 types of external partnerships to support population and/or community health.

This article addresses how social determinants of health (SDOH) increase or decrease the risk of poor health outcomes and why doing so is critical to improving the nation’s health and wellbeing.

This infographic gives step-by-step instructions for using Z Codes. Z Codes are a special group of codes used to document social determinants of health (SDOH) data. SDOH are the conditions in the environments where people are born, live, learn, work, play, worship and age. Such data can ultimately be used with social services organizations, providers, health plans and consumer/patient advisory boards to identify unmet needs.

Nationally standardized and stakeholder-driven, the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) is designed to equip health care organizations and their community partners to better understand and act on individuals’ social drivers of health (SDOH) to improve health equity at the individual, community and systems levels.

These tools can be used by family physicians and their practice teams to screen patients for social determinants of health, identify community-based resources to help them and work with patients to develop an action plan that encompasses social needs to help them overcome health risks and improve outcomes.

The Centers for Medicare and Medicaid Services and the National Center for Health Statistics provide the following guidelines updated April 1, 2023 for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

This fact sheet is part of a series from the Center for Health Care Strategies addressing the impact of limited health literacy and providing strategies for organizational improvement. It defines health literacy, outlines its importance, and describes the impacts of limited health literacy at the individual, organizational and societal levels.

This fact sheet is part of a series from the Center for Health Care Strategies addressing the impact of limited health literacy and providing strategies for organizational improvement. It details the prevalence of limited health literacy and provides assessment strategies for identifying patients with limited health literacy.

This fact sheet is part of a series from the Center for Health Care Strategies addressing the impact of limited health literacy and providing strategies for organizational improvement. It discusses how limited health literacy contributes to health disparities and offers strategies for health care organizations seeking to address these challenges.

This webinar recorded in Spanish for Puerto Rico reviews evidence showing that Social Determinants of Health increase the likelihood of a hospital readmission, and that patients are most at risk for readmission due to new medications or lack of resources. Early identification of patients most at risk for readmissions can reduce a preventable readmission.