Social Determinants: Going Upstream for Whole-Person Care

Share Article

The World Health Organization (WHO) defines social determinants of health (SDoH) as the conditions in which “people are born, grow, work, live, and age, as well as the set of forces and systems that shape daily life.” An estimated 70% of a person’s health outcomes is attributable to SDoH. Traditional clinical care—such as the one-on-one medical care patients get when they visit their doctors’ offices—contributes up to only 10%. 

Momentum to standardize an SDoH screening tool is increasing nationally. WHO, National Academies of Medicine (formerly the Institute of Medicine), and Centers for Disease Control and Prevention all recommend implementing an evidence-based SDoH screening tool in all health care settings. In 2018, the National Quality Forum convened the Social Determinants of Health Data Integration Action Team, comprising more than 40 experts. In 2019, the Action Team published a national call to action for quality and payment innovation in SDoH. 

Addressing social needs within primary care is on its way to becoming a standard of care nationally that will be linked to payments. But the majority of independent primary care providers struggle with the appropriate infrastructure to take on this challenge. A study by Robert Wood Johnson Foundation found that 80% of surveyed health care providers did not feel confident in meeting their patients’ social needs, even though they agreed that social needs interfere with providing quality health care. 

Netrin Health helps providers bridge the gap between knowing that SDoH are important and integrating solutions for social needs at the point-of-care practice. 

 “We have to go upstream to really identify the root cause of why our clients struggle to stay healthy.”

– Sonnie Cody, MPH, Netrin health –

According to the Maryland Primary Care Program (MDPCP), transportation insecurity, social isolation, food insecurity, and financial needs are the areas of greatest social needs for the Medicare population across the state. Rita Pabla, MD, of Padder Health, says, “Now with COVID-19, we are seeing how social determinants of health impacts our patients more than ever before. We see more patients that may be unemployed, have housing instability, and have trouble affording medications or getting access to healthy food.” 

Netrin Health emphasizes whole-person care and helps independent primary care practices implement the Health Leads social determinants screening tool at the point of care. This quick, eight-question tool screens patients for food, financial, transportation, literacy, social isolation, safety, and housing needs. Netrin Health’s care team then links patients with necessary resources across the state and shares our database of social needs resources with our partner practices. 

 “Now with COVID-19, we are seeing how social determinants of health impacts our patients more than ever before.”

– Rita Pabla, MD, padder health –

“We have to go upstream to really identify the root cause of why our clients struggle to stay healthy,” explains Netrin Health care coordinator Sonnie Cody, MPH. For example, while Sonnie was working with “James,” an 86-year-old man with multiple chronic conditions who lived alone, she learned that he had trouble preparing his own food and getting to the grocery store because he lives in a remote area of Maryland.

“I had a hard time managing my health conditions without easy access to meals,” James told Netrin Health. ” I really appreciated how Sonnie walked with me every step of the way in order to sign up for a meal delivery service through the county which I did not know existed.” 

Netrin Health sees SDoH as crucial aspects to address in a patient’s holistic care plan. 

MDPCP gives primary care practices funding they can use to expand chronic care and address the social needs of their Medicare patients. MDPCP emphasizes screening for social needs as a requirement for practices to be deemed Advanced Primary Care for all Medicare patients. 

Primary care practices interested in joining MDPCP for 2021 can apply now. Enrollment for new practices to join in 2021 is open through July 14, 2020. 


Contact Netrin Health today to learn how we can support your practice and your patients during these challenging times. We will help you apply for MDPCP funding and partner with you in the program’s success. 


Gottlieb, L. M., Wing, H., & Adler, N. E. (2017). A systematic review of interventions on patients’ social and economic needs. American Journal of Preventive Medicine, 53(5), 719–729.