The Value of Social Determinants of Health Needs Assessments in Primary Care

Social determinants of health (SDOH) such as income, housing, food security, education, transportation, and healthcare access, exert a far greater influence on health outcomes compared with traditional clinical care alone. This policy commentary argues for the routine integration of SDOH needs assessments into primary care to enable more comprehensive, equitable, and effective patient care. By screening for social drivers, providers can identify non-medical obstacles to treatment adherence, connect patients with community resources, and develop realistic care plans tailored to individual circumstances. Additionally, understanding patients' social environments can help clinicians consider alternative or differential diagnoses associated with specific social exposures. For example, housing instability or poor housing conditions may contribute to respiratory illnesses such as asthma due to mold or environmental exposures, while food insecurity may increase risk for malnutrition or poor control of chronic diseases such as diabetes. Incorporating SDOH information into clinical decision-making therefore not only improves care coordination but also supports more accurate and context-informed diagnostic assessments. A real-world needs assessment conducted with a Delaware State University professor living with a neuromuscular disorder illustrates how even insured, employed, highly educated individuals can face critical gaps in medical device coverage, underscoring the intersection of social and economic factors with clinical care. The commentary further highlights how aggregated SDOH data can inform community-wide public health planning, policy advocacy, and resource allocation. Practical implementation strategies, including digital screening tools embedded in electronic health records, are proposed to minimize workflow disruption while ensuring consistent data collection. Ultimately, embedding SDOH assessments into routine primary care represents an essential step toward holistic, value-based healthcare that addresses root causes of health disparities and improves long-term patient outcomes.