Addressing Patients’ Social Determinants of Health

Module Description

Many of the most persistent gaps, disparities and inefficiencies in healthcare have roots that stretch beyond the boundaries of the traditional healthcare system. They’re the result of social issues like food access, exposure to violence and discrimination, lack of housing, transportation and employment, and income disparity. These problems have profound effects on the efficiency, effectiveness and quality of care. When confronted by these “social issues,” many practitioners throw up their hands and try to focus on providing medical services.  This module pushes the boundaries of healthcare and demonstrates the value of addressing social determinants of health with practical step-by-step instructions for building systems and demonstrating outcomes.

Intended Audience

This course is designed for physicians as well as nurse practitioners, physician assistants, and allied health professionals who are working toward population health management, especially in safety-net settings.

Duration and Fee

Estimated Time to Complete: 1 hour

Registration Fee: $20

CME Credits

This Enduring Material activity, Population Health in the Safety Net, has been reviewed and is acceptable for up to 12.00 Prescribed credit(s) by the American Academy of Family Physicians. AAFP certification begins 10/01/2018. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


Health Management Associates established HMA Community Strategies (HMACS) to address social issues like food access, exposure to violence and discrimination, lack of housing, transportation and employment, and income disparity. Our team brings years of expertise in policy analysis, government, strategic planning, organizational development and other key areas to develop partnerships and engage stakeholders from across the community.

Stephanie Denning has a unique blend of healthcare policy, administration, operations, and marketing experience. She has worked for public, non-profit and private health insurers and public health systems. Maddy Shea has a passion for health equity and the federal, state and local cross-sectoral expertise to guide community health improvement measurement and action. Throughout her career, Maddy has joined forces with housing, planning, energy, food systems, community development, academic and criminal justice organizations to accelerate progress on community health goals.

Maddy and Stephanie bring their expertise to demonstrate in this module how health systems can identify and address social determinants of health and measure outcomes. Their real-world experience will showcase successful models from around the United States.

Stephanie Denning and Maddy Shea disclose that they are employees of Health Management Associates, a national research and consulting firm providing technical assistance to a diverse group of healthcare clients.

Learning Objectives

At the completion of the course, attendees will be able to:

  • Define social determinants of health (SDoH) and explain the value of understanding patients’ SDoH
  • List data sources to delineate SDoH including patient screening and publicly available information
  • Describe models of addressing patients’ SDoH needs and connecting patients to resources
  • List and describe tools for measuring success, defining outcome targets, and determining accomplishments
  • Demonstrate how clinicians can drive change to build meaningful population health interventions