Integrating SDOH Into Practice Key to Improving Outcomes – Medscape

Advancing Health Equity and Sustainable Development Goals through Social Determinants of Health

A report from the American College of Rheumatology (ACR) 2025 Annual Meeting underscores that achieving health equity is fundamental to ensuring quality in healthcare. Jillian Rose-Smith, PhD, MPH, MSW, highlighted that fair and just care for all individuals is a core tenet of Sustainable Development Goal 3 (Good Health and Well-being) and cannot be realized without addressing systemic inequalities, a key target of SDG 10 (Reduced Inequalities). The discussion focused on leveraging data on Social Determinants of Health (SDOH) to improve patient outcomes and align clinical practice with global sustainability targets.

The Critical Role of Social Determinants in Achieving Health-Related SDGs

The report emphasizes that to make substantive progress in population health, healthcare systems must address the conditions in the environments where people live, work, and play. These factors are directly linked to several SDGs and are paramount to patient well-being.

Immediate Threats to Foundational SDGs

The conversation pointed to urgent, real-world challenges that impact health. For instance, the potential loss of food benefits for millions of Americans due to a government shutdown directly threatens SDG 2 (Zero Hunger) and exacerbates conditions of poverty, a focus of SDG 1 (No Poverty). These social determinants create immediate needs that healthcare providers must contend with to provide effective care.

The Human-Centric Approach to Care

It was noted that beyond formal screening, simple human-centric conversation during clinical appointments can uncover critical information about a patient’s life. By inquiring about family, housing, and transportation, providers can identify barriers to health and well-being. This approach helps address the holistic needs of patients, optimizing care and strengthening the provider-patient relationship, which is essential for achieving the targets of SDG 3.

Policy Landscape and Regulatory Frameworks for SDG Integration

Federal Mandates for SDOH Data Collection

Recent federal regulations have institutionalized the collection of SDOH data, creating a framework to address health inequities. As of January 2024, the Centers for Medicare & Medicaid Services (CMS) began reimbursing practitioners for SDOH risk assessments using standardized tools. Hospitals are now required to report on inpatient screening for five key domains of social needs, which directly correlate with multiple SDGs:

• Food insecurity (SDG 2)
• Housing instability (SDG 11)
• Transportation needs (SDG 11)
• Utility difficulties (SDG 1, SDG 7)
• Interpersonal safety

Anticipated Policy Shifts and Future Outlook

A regulatory shift is anticipated, moving from inpatient data collection to mandatory outpatient SDOH reporting by 2026. This proposed rule aims to rebalance policy with a greater focus on prevention, outcome correlation, and automated, targeted approaches to advance health equity. This forward-looking strategy aligns with the proactive and preventative nature of the Sustainable Development Goals, aiming to create more resilient and equitable health systems.

Persistent Disparities Hindering Progress on SDG 10

Despite policy advancements, significant disparities persist, undermining efforts to achieve SDG 10 (Reduced Inequalities). Research indicates that SDOH can account for up to 80-90% of adverse health outcomes.

Case Studies in Rheumatology

Studies presented demonstrate the profound impact of SDOH on patients with rheumatic diseases:

• A 2023 study on lupus found that worse disease outcomes were associated with lower income, lower education, disadvantaged neighborhoods, and lack of social support. Addressing these underlying inequities is necessary to improve patient management.
• A 2024 study on rheumatoid arthritis revealed that each additional adverse SDOH increased a patient’s all-cause mortality risk by 24%. Patients with five or more adverse SDOH had a mortality risk nearly four times higher than those with none.

These findings illustrate how social and economic inequalities create severe health disparities, making the case for targeted public health policies that address SDOH to improve long-term outcomes.

Bridging the Gap: From Data Collection to Actionable SDG Strategies

Challenges in Operationalizing SDOH Data

While data collection on SDOH is increasing, a significant gap remains in translating this information into action. A March 2024 study found that while 68.5% of providers agree that SDOH affect patient outcomes, only 24.1% feel their setting is equipped to address them. An AHIMA report further revealed that while organizations collect data, integration into Electronic Health Records (EHRs) and follow-up on referrals are lacking. This inability to act on collected data can foster mistrust and limit positive health impacts.

A Four-Point Framework for Effective Implementation

To bridge the gap between policy and practice, a four-point framework was proposed to help healthcare systems effectively integrate SDOH into clinical workflows. This approach supports SDG 17 (Partnerships for the Goals) by fostering collaboration within and outside the health system.

1. Workflow Alignment: Embed and automate SDOH screening within existing clinical processes and EHRs to standardize data collection.
2. A Team-Based Approach: Utilize a shared responsibility model where physicians identify needs and refer to social workers or patient navigators for follow-up, preventing clinician burnout.
3. Resource Mapping: Build and maintain a directory of local community resources by establishing partnerships with food banks, housing organizations, and transportation programs.
4. Closing the Loop: Develop closed-loop referral systems to track whether patients successfully accessed services and had their needs met, ensuring accountability and measuring impact.

Conclusion: Fostering Collaborative Partnerships for Sustainable Health Outcomes

The report concludes that the collection of SDOH data must be paired with adequate follow-up and support to be effective. Building collaborative partnerships with community organizations, health information technology experts, and digital platforms is crucial. This teamwork approach, a core principle of SDG 17, can streamline processes, automate referrals, and reduce the burden on individual providers. By effectively leveraging SDOH information, the healthcare sector can move beyond treating illness to actively promoting equity and well-being, making significant strides toward achieving SDG 3 and SDG 10.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 1: No Poverty

  The article connects poverty and low income directly to adverse health outcomes. It cites studies where “lower income” is associated with worse disease outcomes in lupus patients and is a factor, along with unemployment, that increases mortality risk in rheumatoid arthritis patients. This highlights the link between economic status and health, which is central to SDG 1.

• SDG 2: Zero Hunger

  The article explicitly addresses food insecurity as a critical social determinant of health (SDOH). It mentions “food insecurity” as one of the five key areas for which clinicians screen patients and warns that “millions of Americans will lose their food benefit,” directly linking food access to health and well-being.

• SDG 3: Good Health and Well-being

  This is the central theme of the article. The entire discussion revolves around achieving “health equity,” which it defines as “fair and just care for everyone.” It explores how addressing SDOH is essential for improving “the quality of care and the outcomes of our patients” and reducing disparities in health, which is the core mission of SDG 3.

• SDG 4: Quality Education

  The article identifies education level as a significant factor in health disparities. It notes that studies found worse health outcomes associated with “lower education levels” and that having “less than a high school education” was linked to a higher mortality risk, connecting educational attainment to health equity.

• SDG 10: Reduced Inequalities

  The article’s focus on “health equity” and persistent “disparities” directly addresses SDG 10. It discusses how health outcomes are negatively affected by factors like income, education, race (“anti-Black racism”), and living in “disadvantaged neighborhoods,” emphasizing the need to reduce these inequities to improve population health.

• SDG 11: Sustainable Cities and Communities

  The article touches upon elements of SDG 11 by identifying “housing instability,” “transportation needs,” and “utility difficulties” as key SDOH that impact a patient’s ability to access care and maintain health. These factors relate to the quality and accessibility of housing, basic services, and transport systems within communities.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 1.2: Reduce at least by half the proportion of men, women and children of all ages living in poverty.

   The article’s emphasis on how “low income” contributes to poor health outcomes and increased mortality risk aligns with the goal of reducing poverty. Addressing income-related health barriers is a step toward mitigating the broader impacts of poverty discussed in this target.

2. Target 2.1: By 2030, end hunger and ensure access by all people… to safe, nutritious and sufficient food all year round.

   This target is directly relevant to the article’s discussion of “food insecurity” as a key SDOH. The implementation of screening tools by healthcare providers to identify patients facing food insecurity is a direct action aimed at identifying those who lack access to sufficient food.

3. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services…

   The article’s core message about providing “fair and just care for everyone” and overcoming barriers like “transportation challenges that prevent them from receiving medical care” directly supports this target. The push to integrate SDOH into clinical care is a strategy to ensure more equitable access to quality healthcare.

4. Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… race… or economic or other status.

   The article highlights the need to address health disparities stemming from economic status (“lower income”), education level, and race (“anti-Black racism”). The effort to achieve health equity by understanding and addressing these social factors is a practical application of promoting inclusion and reducing inequalities in the context of health.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

• Screening Rates for Social Needs

  The article states that since 2024, hospitals “are required to report how many inpatients are screened for health-related social needs and the screen positive rate for those with at least one need in any of the five areas.” These five areas include food insecurity, housing instability, and transportation needs. This “screen positive rate” serves as a direct indicator of the prevalence of these social challenges within the patient population.

• Prevalence of Barriers to Healthcare

  The article provides a specific statistic that can be used as an indicator: “3.6 million Americans have transportation challenges that prevent them from receiving medical care each year.” Tracking the reduction of this number would indicate progress in improving access to care (Target 3.8).

• Healthcare System Capacity to Address SDOH

  An implied indicator is the capacity of healthcare systems to manage SDOH. The article cites a study where “less than a quarter (24.1%) said their setting is equipped to address SDOH.” Measuring an increase in this percentage would indicate progress in building the infrastructure needed to achieve health equity.

• Disparities in Health Outcomes

  The article implies that disparities in health outcomes can be measured. It references studies that found “worse disease and psychosocial outcomes associated with lower income, lower education levels… [and] anti-Black racism” and a “24%” increase in mortality risk for each additional SDOH. Tracking the reduction of these outcome gaps between different demographic and socioeconomic groups would be a key indicator of progress toward SDG 10.

• Integration of SDOH Data into Electronic Health Records (EHR)

  The article points to a gap between data collection and its use, noting that while 80% of organizations collect data on homelessness, “barely half (53%) integrate it into EHRs.” The percentage of SDOH data successfully integrated into EHRs is a measurable indicator of the health system’s ability to act on this information.

4. Table of SDGs, Targets, and Indicators

Source: medscape.com