Social Determinants of Health in Care Management

Social determinants of health (SDOH) are the non-clinical conditions in which people are born, grow, work, live, and age that shape health outcomes as significantly as medical care itself. This page provides a reference-grade treatment of how SDOH are defined, classified, and operationalized within care management programs across payer, provider, and public health contexts in the United States. The content covers regulatory frameworks, causal pathways, classification boundaries, and the structural tensions that arise when clinical and social care systems intersect. Understanding SDOH within care management models and frameworks is foundational to population-level intervention design.

• Definition and scope
• Core mechanics or structure
• Causal relationships or drivers
• Classification boundaries
• Tradeoffs and tensions
• Common misconceptions
• Checklist or steps (non-advisory)
• Reference table or matrix

Definition and scope

The Centers for Disease Control and Prevention (CDC) defines social determinants of health as "conditions in the places where people live, learn, work, and play that affect a wide range of health and functioning outcomes and risks" (CDC, SDOH Overview). Healthy People 2030, the federal health promotion framework administered by the U.S. Department of Health and Human Services (HHS), organizes SDOH into 5 primary domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (HHS, Healthy People 2030).

Within care management, scope extends beyond screening. The Centers for Medicare & Medicaid Services (CMS) has embedded SDOH assessment requirements into several billing codes, including the Chronic Care Management (CCM) codes (99490–99491) and the Transitional Care Management (TCM) codes (99495–99496), which specify that care plans must address patient needs across social and functional domains, not only clinical diagnoses (CMS, Chronic Care Management). The ICD-10-CM Z-code series (Z55–Z65) provides a standardized diagnostic coding framework for documenting SDOH-related conditions, enabling capture of issues such as food insecurity (Z59.4), inadequate housing (Z59.1), and low income (Z59.6) in the medical record (CDC, ICD-10-CM).

The practical scope for care managers spans individual-level screening through community-level data aggregation, linking population health management strategies to the discrete social needs of high-risk patients.

Core mechanics or structure

SDOH integration in care management operates through four sequential structural components: screening, documentation, referral, and outcome tracking.

Screening instruments are the front-end tools used to identify social needs. Validated instruments include the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), developed by the National Association of Community Health Centers (NACHC); the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool, developed by CMS and deployed across 32 core screening questions targeting housing instability, food insecurity, transportation, utilities, and interpersonal safety (CMS, AHC Model); and the SDOH screening section embedded in the Electronic Health Record (EHR) vendor Gravity Project's structured data standards, now maintained through HL7 FHIR-based clinical terminology (Gravity Project).

Documentation pathways rely on ICD-10-CM Z-codes and, increasingly, LOINC (Logical Observation Identifiers Names and Codes) panel codes approved for SDOH data capture in structured EHR fields. The Gravity Project has defined 27 SDOH domains with corresponding coded content for clinical data exchange as of its published consensus standards.

Referral mechanisms connect identified needs to community resources. The 211 network, coordinated nationally through United Way Worldwide and the Alliance of Information and Referral Systems (AIRS), provides the primary infrastructure for community resource directories used by care management teams.

Outcome tracking requires closed-loop referral systems that confirm whether a referred service was received, a function partially addressed by platforms using the FHIR-based Social Services Referral (SSR) implementation guide endorsed by HL7 International. Health information technology in care management infrastructure increasingly supports this closed-loop function.

Causal relationships or drivers

SDOH drive health outcomes through biological, behavioral, and systems-level pathways. Research published by the Robert Wood Johnson Foundation (RWJF) and cited by the CDC attributes approximately 30–55% of health outcomes to social and economic factors, with health behaviors accounting for an additional 30% — leaving clinical care responsible for only 10–20% of measurable health outcomes (County Health Rankings Model, RWJF).

At the individual level, food insecurity produces chronic stress responses that dysregulate the hypothalamic-pituitary-adrenal axis, increasing cortisol exposure and elevating risk for metabolic and cardiovascular conditions. Housing instability disrupts medication storage, adherence schedules, and follow-up appointment attendance. Low educational attainment correlates with reduced health literacy, a factor the Agency for Healthcare Research and Quality (AHRQ) has linked to higher rates of avoidable hospitalizations (AHRQ Health Literacy).

At the structural level, residential segregation — a product of documented federal housing policy through the mid-20th century — creates concentrated poverty zones with reduced access to grocery stores, parks, primary care, and quality schools. The CDC's Social Vulnerability Index (SVI) quantifies these compound exposures across 15 census-level variables grouped into 4 themes: socioeconomic status, household characteristics, racial/ethnic minority status, and housing type/transportation (CDC SVI).

Risk stratification in care management programs that incorporate SDOH data alongside clinical data demonstrate stronger predictive validity for avoidable utilization than models relying on claims data alone, based on published findings from the Camden Coalition of Healthcare Providers and the Comprehensive Primary Care Plus (CPC+) model evaluations.

Classification boundaries

SDOH classification in care management requires distinguishing between three overlapping but distinct categories:

Social needs are individual-level deficits identified through patient screening — specific, actionable, and addressable through referral or care plan modification. Example: a patient with diabetes (linked to diabetes care management) who screens positive for food insecurity receives a referral to a SNAP enrollment navigator.

Social risk factors are population-level attributes associated with elevated health risk at the group level. These are measured through administrative data, census data, or the CDC SVI and applied in population health management stratification models. They inform program design but do not substitute for individual screening.

Social determinants (the broad category) encompass the upstream structural and policy-level forces — income inequality, housing markets, educational infrastructure, discriminatory policy — that generate both individual social needs and population social risk factors. These are generally not addressable within a single care management episode.

CMS has differentiated these tiers operationally: the AHC Model targets individual social needs, while value-based payment models (such as ACO REACH) incentivize addressing population-level social risk factors through the health equity benchmark adjustments introduced in the ACO REACH Model (CMS, ACO REACH).

The Joint Commission (TJC) includes SDOH screening in its accreditation standards under the Patient-Centered Communication standards, requiring accredited hospitals to assess patient needs across six domains that map to HHS's Healthy People 2030 SDOH framework (The Joint Commission).

Tradeoffs and tensions

Data sharing versus privacy: SDOH data collected in a clinical encounter is subject to HIPAA's Privacy Rule (HHS, HIPAA), but referral data transmitted to community-based organizations (CBOs) may not be — creating asymmetric protection for sensitive social data. Consent frameworks vary by state. Some states require explicit written consent before sharing SDOH information with non-covered entities.

Screening burden versus clinical capacity: Validated SDOH tools like PRAPARE contain 21 core questions. Administering them in primary care visits competes with clinical assessment time. Studies funded through AHRQ found that practices without dedicated care coordinators had lower SDOH screening completion rates, suggesting that care manager roles and responsibilities are a structural prerequisite for consistent screening.

Referral without resolution: Identifying a social need without a mechanism to resolve it can harm patient trust. The gap between need identification and service availability — particularly in rural geographies where 211 resource databases are less complete — produces referral dead-ends that registered in CMS's AHC Model evaluation findings.

Risk scoring and algorithmic bias: Predictive models that incorporate SDOH variables may replicate historical inequities if trained on data where prior utilization reflects access barriers rather than clinical need. The National Academy for State Health Policy (NASHP) has documented this tension in Medicaid risk stratification programs.

Common misconceptions

Misconception: SDOH screening is optional or supplemental. CMS billing requirements for CCM and TCM codes explicitly require that care plans address patient social and functional needs. Non-clinical needs are not supplemental — they are a billable care plan component.

Misconception: Z-codes do not affect reimbursement. ICD-10-CM Z-codes do not typically drive diagnosis-related group (DRG) payment, but they do affect risk adjustment in value-based models. The HHS-HCC (Hierarchical Condition Category) risk adjustment model used in Medicare Advantage is being examined for SDOH-inclusive updates by CMS's Center for Medicare and Medicaid Innovation (CMMI).

Misconception: SDOH and behavioral health are the same domain. Behavioral health conditions such as depression and substance use disorder are clinical diagnoses, not social determinants. However, SDOH exposures (e.g., adverse childhood experiences, poverty) are significant drivers of behavioral health conditions — a relationship covered in behavioral health care management reference frameworks.

Misconception: SDOH interventions produce immediate cost savings. CMS evaluations of the AHC Model (2017–2022 cohort) found mixed evidence on total cost of care reduction within 2-year program windows, consistent with the longitudinal nature of social needs resolution.

Checklist or steps (non-advisory)

The following sequence describes the structural phases of an SDOH integration workflow within a care management program. This is a reference description of documented practice patterns — not clinical or legal guidance.

1. Population identification — Select the patient cohort for SDOH screening using clinical risk scores, utilization patterns, or enrollment in qualifying programs (e.g., CCM, TCM, Medicaid managed care).
2. Screening tool selection — Choose a validated instrument (PRAPARE, AHC HRSN, WellRx, or equivalent) aligned with the care setting and EHR capability for structured data capture.
3. Administration and documentation — Administer screening in the care encounter or via secure patient portal; document responses using ICD-10-CM Z-codes and/or LOINC-coded SDOH panels in the EHR.
4. Need prioritization — Identify which identified social needs are actionable within the patient's geography and the program's referral network capacity.
5. Resource matching — Cross-reference identified needs with the 211 community resource database, closed-loop referral platforms (e.g., NowPow, findhelp.org), or organization-specific CBO partnerships.
6. Referral initiation and consent — Document consent for data sharing with non-HIPAA-covered community partners where state law or organizational policy requires it.
7. Closed-loop confirmation — Track whether referrals resulted in service receipt, using platform-generated status updates or follow-up patient contact.
8. Care plan update — Integrate SDOH findings and referral status into the patient's care plan, linking social needs to clinical goals (e.g., housing stability linked to medication adherence targets).
9. Outcome documentation — Record SDOH-related outcomes in the EHR and aggregate de-identified data for program-level quality reporting aligned with care management quality metrics.
10. Program evaluation — Review SDOH screening rates, referral completion rates, and need-resolution rates at defined intervals to assess program function.

Reference table or matrix

Sources for table: HHS Healthy People 2030; CDC ICD-10-CM; CMS AHC Model; NACHC PRAPARE.

References

• CDC — Social Determinants of Health Overview
• HHS — Healthy People 2030, Social Determinants of Health
• CMS — Chronic Care Management Fact Sheet
• CMS — Accountable Health Communities Model
• CMS — ACO REACH Model
• CDC — ICD-10-CM Official Guidelines
• CDC — Social Vulnerability Index (SVI)
• [AHRQ — Health Literacy](https://www.ahrq.gov/health-literacy/index.html