CCPP Module 11, Section 4: Addressing Social Determinants of Health
MODULE 11: PATIENT IDENTIFICATION AND RISK STRATIFICATION

Section 11.4: Addressing Social Determinants of Health

From Prescription to Person: Integrating the Social Context into a Holistic Model of Care.

SECTION 11.4

Addressing Social Determinants of Health

Learn to identify and integrate non-clinical factors like transportation, housing, and food security into your risk assessment to provide truly holistic care.

11.4.1 The “Why”: The Limits of the Biomedical Model

As a pharmacist, you have been rigorously trained in the biomedical model of care. This framework, which has dominated healthcare for the last century, views disease as a malfunction of the biological and physiological systems of the human body. Your expertise lies in correcting these malfunctions with precisely targeted pharmacological interventions. You are a master of pharmacokinetics, pharmacodynamics, and pathophysiology. This model is incredibly powerful and has been responsible for monumental advances in human health. It is also, on its own, profoundly incomplete.

The hard truth that every experienced healthcare provider eventually confronts is that the most elegant, evidence-based, guideline-directed medication regimen is utterly useless if the patient cannot afford it, cannot get to the pharmacy to pick it up, does not have a stable place to store it, or is forced to choose between buying their insulin and feeding their family. Clinical factors determine what a patient should do; social factors often determine what a patient can do. It is in this gap between the “should” and the “can” that medication non-adherence thrives, chronic diseases spiral out of control, and health inequities become entrenched.

This is the critical juncture where we must expand our perspective to embrace the concept of Social Determinants of Health (SDOH). As defined by the World Health Organization and Healthy People 2030, SDOH are the “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” To put it more bluntly: a patient’s zip code is often a better predictor of their health outcomes than their genetic code.

For the collaborative practice pharmacist, engaging with SDOH is not “mission creep” or “social work.” It is the pinnacle of comprehensive medication management. It is the recognition that the most significant barrier to therapeutic success may not be a drug interaction or a dosing error, but the fact that a patient’s electricity was turned off and their insulin has spoiled in a warm refrigerator. Identifying and mitigating these non-clinical barriers is not adjacent to your job; it is central to it. It is the only way to provide care that is not just clinically sound, but also compassionate, equitable, and truly effective in the complex reality of your patients’ lives.

Pharmacist Analogy: The Unstable Foundation

Imagine you are a master pharmacist tasked with designing the perfect, state-of-the-art medication adherence packaging for a patient. You create a beautiful, customized blister pack with color-coded, easy-to-read labels for each day. You even include a built-in alarm that beeps when it’s time to take a dose. The design is flawless. This adherence pack represents the perfect biomedical plan.

You proudly give this to your patient. A month later, they return to the hospital with their condition uncontrolled. You are baffled. Your adherence pack was perfect. But when you investigate, you discover the truth: the patient is experiencing homelessness and lives in a shelter. They have no secure place to store the pack, it got wet in the rain, and they were afraid the beeping alarm would attract unwanted attention. The foundation upon which you placed your perfect plan—the assumption that the patient had a safe, stable home—was non-existent. Your elegant solution failed because it did not account for the patient’s social reality.

Addressing Social Determinants of Health is the work of a master builder. Before you construct the intricate architecture of a medication regimen (the walls, the roof, the electrical wiring), you must first inspect the foundation. Is it stable? Are there cracks? Is the ground beneath it solid? Asking about housing, food, transportation, and income is not a detour from your clinical work; it is the essential first step of a structural engineer ensuring that the brilliant clinical plan you are about to build has a chance to actually stand.

11.4.2 The Five Domains of SDOH: A Pharmacist’s Field Guide

To systematically address SDOH, we need a framework. The Healthy People 2030 initiative organizes SDOH into five key domains. As a collaborative practice pharmacist, you must become fluent in the language of these domains and, more importantly, develop a keen clinical eye for how each one directly influences medication access, adherence, and outcomes. This framework will transform your patient interviews from a simple medication history into a holistic assessment of the patient’s life context.

In the following tables, we will conduct a deep dive into each domain, translating abstract social concepts into the concrete, medication-related problems you will encounter and solve every single day.

Domain 1: Economic Stability

The Core Issue: The patient’s ability to consistently meet their basic needs. This domain encompasses poverty, employment, food security, and housing stability. For many patients, financial strain is the single most powerful driver of their health decisions.

Masterclass Table: Economic Stability and its Medication-Related Consequences
Specific Barrier How it Manifests as a Medication Problem Pharmacist’s Screening Questions & Probes High-Impact Pharmacist Interventions
Cost of Medications / Underinsurance This is the most direct link. Patients will intentionally skip doses, split pills, or simply never fill a prescription to save money. This is not “non-compliance”; it is cost-related non-adherence.
  • “Many people find it hard to afford their medications. In the last year, have you had to choose between paying for your medicine and paying for other things like food or rent?”
  • “Do you ever find yourself skipping doses or splitting pills to make a prescription last longer?”
  • Perform a cost-saving analysis: Switch to generics, preferred formulary agents, or 90-day supplies.
  • Enroll patient in manufacturer Patient Assistance Programs (PAPs) or copay card programs.
  • Connect patient to state pharmaceutical assistance programs or the Extra Help program for Medicare Part D.
Food Insecurity A patient with diabetes may ration or skip insulin doses if they are unsure where their next meal is coming from, fearing hypoglycemia. The “heat or eat” dilemma becomes “insulin or eat.” Medications that must be taken with food may be taken on an empty stomach, reducing efficacy or increasing GI side effects.
  • “Within the past 12 months, did you worry that your food would run out before you got money to buy more?”
  • “Within the past 12 months, did the food you bought just not last, and you didn’t have money to get more?”
  • Provide education on managing diabetes during periods of inconsistent food intake.
  • Switch to medications with a lower risk of hypoglycemia (e.g., from a sulfonylurea to a DPP-4 inhibitor).
  • Provide a “warm handoff” referral to a social worker or community health worker who can connect the patient to SNAP (food stamps), WIC, or local food pantries.
Housing Instability Patients experiencing homelessness or living in unstable housing (e.g., shelters, couch surfing) have no secure place to store medications. Refrigerated items like insulin are nearly impossible to manage. Lost or stolen medications are common. Mail-order pharmacies are not a viable option.
  • “In the past 2 months, have you been worried you might lose your housing?”
  • “Do you have a safe and stable place to store your medications?”
  • “Do you have a working refrigerator?”
  • Switch from vials to pens for insulin, which can often be kept at room temperature for longer periods.
  • Consolidate the regimen to the fewest number of pills possible, ideally once-daily dosing.
  • Work with the patient’s community pharmacy to arrange for frequent, small-quantity dispensing (e.g., 7-day supplies).
  • Refer to social work for housing assistance resources.

Domain 2: Education Access and Quality

The Core Issue: The patient’s ability to understand and act on health information. This domain includes health literacy, language proficiency, and general educational attainment. It directly impacts a patient’s capacity to navigate the complex world of medications and chronic disease.

Masterclass Table: Education and its Medication-Related Consequences
Specific Barrier How it Manifests as a Medication Problem Pharmacist’s Screening Questions & Probes High-Impact Pharmacist Interventions
Low Health Literacy Patients may not understand prescription labels, warning stickers, or complex instructions. They may not grasp the reason they are taking a medication, leading to unintentional misuse or discontinuation. They may be unable to read written educational materials.
  • “How confident are you in filling out medical forms by yourself?” (A validated single-item screening question).
  • Instead of asking “Do you have any questions?”, say “What questions do you have?”
  • Observe for clues: patient asks to “read it later,” follows text with a finger, or seems to agree without asking clarifying questions.
  • ALWAYS use the Teach-Back method. “Just to be sure I explained this clearly, can you tell me in your own words how you are going to take this new blood pressure pill?”
  • Use plain, jargon-free language. Write instructions at a 5th-grade reading level.
  • Utilize visual aids: pictograms, color-coded charts, medication calendars.
  • Simplify the regimen: The simplest regimen is the easiest to understand.
Language Barriers Patients with limited English proficiency cannot read English prescription labels or educational materials. They may misunderstand verbal instructions, leading to critical dosing errors, especially with high-risk medications like anticoagulants or insulin.
  • “What language do you feel most comfortable speaking when we discuss your health?”
  • Document the patient’s preferred language prominently in the EHR.
  • ALWAYS use a certified medical interpreter for any clinical conversation. Using family members (especially children) as interpreters is inappropriate and dangerous. Become an expert at using your health system’s interpreter services (phone, video, in-person).
  • Provide written materials in the patient’s preferred language.
  • Connect with community pharmacies that offer prescription labels in different languages.

Domain 3: Health Care Access and Quality

The Core Issue: The patient’s ability to get to and navigate the healthcare system itself. This domain looks at barriers like lack of transportation, insurance coverage gaps, and ability to get timely appointments.

Masterclass Table: Healthcare Access and its Medication-Related Consequences
Specific Barrier How it Manifests as a Medication Problem Pharmacist’s Screening Questions & Probes High-Impact Pharmacist Interventions
Transportation Barriers Patients miss appointments for monitoring, leading to gaps in care and unfilled prescriptions. They cannot get to the pharmacy to pick up medications or to the lab for critical monitoring (e.g., INRs for warfarin). Rural patients may live miles from the nearest pharmacy.
  • “In the past year, have you missed or had to reschedule a doctor’s appointment because you couldn’t get a ride?”
  • “Is getting to the pharmacy to pick up your prescriptions a challenge for you?”
  • Utilize telehealth (video or phone) visits for your CMM service to eliminate the need for the patient to travel.
  • Help the patient sign up for a mail-order pharmacy or a community pharmacy that offers delivery services.
  • Refer the patient to a social worker or case manager who can arrange for non-emergency medical transportation (NEMT), often a covered benefit under Medicaid.
Lack of a Usual Source of Care / Fragmented Care Patients who use the emergency department as their primary care source have no consistent provider managing their chronic medications. This leads to therapeutic duplication, gaps in therapy, and uncontrolled conditions. They may see multiple specialists who do not communicate with each other.
  • “Who do you consider to be your main doctor or clinic?”
  • Review the EHR for notes from multiple providers and the prescription fill history for prescriptions from multiple, uncoordinated sources.
  • You become the source of continuity. Your role in performing a best-possible medication history and creating a single, reconciled medication list is invaluable.
  • Serve as the communication hub, ensuring that the cardiologist, endocrinologist, and primary care provider are all aware of the full medication regimen.
  • Work to establish the patient with a primary care home.

Domain 4: Neighborhood and Built Environment

The Core Issue: The physical environment where the patient lives. This includes the safety of their neighborhood, access to healthy foods, water quality, and exposure to crime and violence. Chronic stress from living in an unsafe environment can have direct physiological effects that worsen chronic disease.

Masterclass Table: Neighborhood and its Medication-Related Consequences
Specific Barrier How it Manifests as a Medication Problem Pharmacist’s Screening Questions & Probes High-Impact Pharmacist Interventions
“Pharmacy Deserts” & Lack of Access to Healthy Food A patient may live in a neighborhood with no pharmacies within walking distance and limited public transit. Their only food options may be convenience stores and fast-food restaurants, making it nearly impossible to follow a heart-healthy or diabetic diet.
  • “Where do you usually go to buy your groceries? How do you get there?”
  • “Is there a pharmacy that is convenient for you to get to?”
  • Again, mail-order or delivery pharmacy is a key intervention.
  • Provide realistic dietary counseling that accounts for the patient’s actual food options. Focus on harm reduction rather than ideal dietary purity.
  • Connect patients with community-based organizations that offer mobile markets or healthy food delivery.
Neighborhood Safety An elderly patient may be afraid to walk to the bus stop to get to their appointment or pharmacy due to neighborhood crime. The chronic stress of living in a violent environment can raise blood pressure and blood glucose, making clinical targets harder to achieve.
  • “Do you feel safe in your neighborhood?”
  • “Are there any challenges in your neighborhood that make it hard for you to get out and about?”
  • This is a difficult area for direct intervention, but acknowledging the patient’s stress is a powerful therapeutic act in itself.
  • Telehealth services become even more critical for these patients.
  • Referral to behavioral health services to help with coping strategies for chronic stress.

Domain 5: Social and Community Context

The Core Issue: The patient’s network of relationships and social support. This domain encompasses social isolation, loneliness, discrimination, and caregiver responsibilities. A patient’s ability to manage their health is profoundly influenced by the strength and stability of their social fabric.

Masterclass Table: Social Context and its Medication-Related Consequences
Specific Barrier How it Manifests as a Medication Problem Pharmacist’s Screening Questions & Probes High-Impact Pharmacist Interventions
Social Isolation / Lack of Support An elderly patient living alone may have no one to help them pick up prescriptions, remind them to take their medications, or help them if they experience a side effect like hypoglycemia. Loneliness itself is a major risk factor for depression, which in turn worsens adherence.
  • “How often do you get together with friends or relatives?”
  • “Is there anyone who helps you with your medications if you need it?”
  • Your regular follow-up calls become a crucial social touchpoint for these patients.
  • Simplify the regimen as much as possible to facilitate self-management. Use adherence packaging (pill boxes) and set up auto-refills.
  • Refer to social work or community organizations that offer “friendly visitor” programs or senior center activities.
Caregiver Burden The patient may be the primary caregiver for a spouse, child, or parent. Their own health needs and appointments become a lower priority. They may be too exhausted or overwhelmed to manage their own complex medication regimen.
  • “Are you currently taking care of anyone else, like a family member or friend?”
  • “How does your role as a caregiver affect your ability to manage your own health?”
  • Acknowledge and validate their difficult situation. Emphasize that taking care of their own health is essential for them to continue caring for their loved one.
  • Make your CMM service as convenient as possible (telehealth, flexible scheduling).
  • Refer them to caregiver support groups or respite care services in the community.

11.4.3 The Practical Toolkit: Systematic Screening for SDOH

Understanding the domains of SDOH is the first step. The next is to integrate a systematic process for identifying these barriers into your clinical workflow. Relying on patients to spontaneously volunteer this sensitive information is unreliable. It requires a proactive, empathetic, and standardized screening process. The goal is to make asking about these life challenges as routine and non-judgmental as asking about medication allergies.

Creating a Safe Space: The Prelude to Screening

Before you ask the first question, you must set the stage. Patients will not disclose sensitive information unless they feel safe and trust that you are asking for the right reasons. Start your screening with a framing statement:

The Script: “Mrs. Jones, to make sure we create the best possible medication plan for you, it’s really helpful for me to understand a little bit more about your day-to-day life. Things like stress, cost, and getting around can have a big impact on your health, and knowing about these challenges helps me to be a better pharmacist for you. I’m going to ask you a few questions that we ask all of our patients. Please know that this is a safe space, your answers are confidential, and if there are any questions you’re not comfortable with, you absolutely don’t have to answer them. Is that okay?”

Leveraging Validated Screening Tools

While you can ask your own questions, using a standardized, validated screening tool has several advantages: it ensures you are comprehensive, it uses patient-tested language, and it often allows for structured data entry into the EHR. You don’t need to administer the entire tool every time, but being familiar with their structure and key questions is invaluable. Your organization may already have a preferred tool integrated into the EHR.

Masterclass Table: Overview of Common SDOH Screening Tools
Tool Name Focus Area Key Features Best Use Case for a Pharmacist
PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) Comprehensive. Covers all major SDOH domains, with a focus on collecting data that aligns with national initiatives.
  • Developed for community health centers.
  • Aligns with EHR data elements (UDS).
  • Includes questions about assets and strengths, not just deficits.
 When your organization is committed to a comprehensive, system-wide SDOH data collection strategy. You might be asked to help administer this as part of a team-based workflow.
The AHC-HRSN Screening Tool (Accountable Health Communities Health-Related Social Needs) Focused on key “core” domains with the strongest evidence link to health outcomes: housing, food, transportation, utilities, and interpersonal safety.
  • Developed by CMS for a large-scale intervention model.
  • Relatively brief (10 questions).
  • Focuses on immediate, actionable needs.
 Excellent for a busy clinical setting where you need a rapid, evidence-based screen to identify the most urgent, high-priority needs that directly impact healthcare utilization.
“EveryONE Project” Social Needs Screening Tool (American Academy of Family Physicians) Designed for seamless integration into primary care workflows.
  • Very brief and user-friendly.
  • Comes with a toolkit for implementation and connecting to resources.
  • Uses simple, patient-centered language.
 A fantastic starting point for a pharmacist in a primary care clinic looking to introduce SDOH screening. You can easily adapt its questions into your CMM interview.

11.4.4 From Screening to Solution: The Pharmacist’s Role as a Connector

Identifying an SDOH barrier is only half the battle. The crucial next step is to connect the patient with resources that can help mitigate that barrier. It is important to define your role clearly: You are not expected to personally solve the patient’s housing crisis or find them a job. You are, however, uniquely positioned to act as a knowledgeable and compassionate “connector.” Your role is to be aware of the available resources, to facilitate a warm handoff to the right person or organization, and to follow up to ensure the connection was made. This requires you to build your own internal “formulary” of community resources and referral pathways.

Building Your Resource Referral Network

Internal Resources (Your First Call)

Your most important partners are within the walls of your own healthcare system. Identify and build strong relationships with:

  • Social Workers: Experts in navigating complex social systems, benefits applications (Medicaid, disability), and crisis intervention.
  • Case/Care Managers: Often nurses who coordinate complex care plans, arrange home health, and manage high-utilizer populations.
  • Financial Counselors: Experts in hospital charity care programs, insurance enrollment, and managing medical debt.

External Community Resources (Your Lifelines)

No health system can meet every need. You must curate a list of key external partners:

  • Area Agency on Aging: A crucial resource for older adults, providing services like Meals on Wheels, transportation, and caregiver support.
  • 2-1-1 / FindHelp.org: National databases (searchable by zip code) of community resources for everything from food pantries to utility assistance to legal aid.
  • Local Public Health Department: Often provides health education, screenings, and connections to other community services.

Masterclass Table: The SDOH Intervention Playbook
Identified SDOH Barrier Immediate Pharmacist Action The “Warm Handoff” Referral Documentation & Follow-Up Plan
Medication Cost Perform a real-time formulary check and cost analysis. Apply for an online copay coupon with the patient. Provide a 1-month sample if available. Switch to a lower-cost therapeutic alternative if allowed by your CPA. “Mrs. Smith, it looks like even with the coupon, this medicine is expensive. I’m going to send a referral to our clinic’s financial counselor. They are experts at signing people up for long-term patient assistance programs that can often provide the medicine for free. Would it be okay if I have them call you?” Document the barrier and your actions in the progress note. Set a task to follow up in 2 weeks to ensure the patient was contacted by the financial counselor and successfully enrolled in the PAP.
Food Insecurity Provide education on managing medications (especially for diabetes) with variable food intake. If possible, provide an on-site emergency box of non-perishable food if your clinic has a pantry. “Mr. Davis, thank you for sharing that with me. No one should have to worry about having enough food. We have a social worker right here in our clinic, Maria, whose entire job is to connect patients with resources like SNAP and local food banks. I’m going to walk you over to her office right now just to introduce you.” Document the positive food insecurity screen. Document the successful warm handoff to social work. In your follow-up call, ask the patient if they were able to connect with the resources provided.
Transportation Barrier Immediately assess if future visits can be converted to telehealth. Check if the patient’s insurance plan has a transportation benefit. Help them explore mail-order or local pharmacy delivery options. “Mr. Chen, since getting to the clinic is a challenge, I’ve scheduled our next visit as a phone call. For getting to other appointments, I’m sending a message to our case management team. They can determine if your insurance covers medical transport and can help arrange rides for you. Expect a call from them in the next few days.” Document the transportation barrier. Document your conversion of the visit to telehealth and the referral to case management. Verify with case management that the referral was received and acted upon.

11.4.5 Documenting and Integrating SDOH into the Care Plan

Your final operational task is to ensure that SDOH-related findings are not just ephemeral conversations but are formally integrated into the patient’s permanent medical record and overall care plan. This accomplishes two goals: it communicates these critical barriers to the entire care team, and it allows your organization to track SDOH data at a population level, which is becoming increasingly important for quality reporting and health equity initiatives.

The most effective way to do this is to treat an identified SDOH barrier as you would any other clinical problem: give it a formal place on the problem list and address it directly in your assessment and plan.

Elevating SDOH to the Problem List

Work with your clinical informatics team to ensure there are specific, codable (using ICD-10 “Z codes”) entries for social determinants of health that can be added to the patient’s official problem list. When you identify a barrier, you should add it, just as you would add “Hypertension.”

Examples of Z Codes:

  • Z59.0: Homelessness
  • Z59.4: Lack of adequate food and safe drinking water
  • Z59.5: Extreme poverty
  • Z55.3: Underachievement in school (relates to health literacy)
  • Z60.2: Problems related to living alone

Documenting these codes transforms a social issue into structured data that can be tracked, reported, and used for population-level analysis and resource planning.

The Socially-Informed SOAP Note: An Example

Let’s revisit our CMM SOAP note template, this time for a patient where SDOH are the primary barriers to care.

  • Patient: 68-year-old female with T2DM, HFrEF, and Hypertension.
  • Subjective: Patient reports “feeling okay” but states she often skips her evening insulin dose because “I’m not very hungry for dinner and I’m afraid my sugar will go low.” She also reports that her new medication for heart failure, Entresto, is “too expensive,” and she has not filled the last prescription. On screening, she endorses food insecurity (“the food runs out by the end of the month”).
  • Objective: BP 155/88. A1c 9.2%. eGFR 55.
  • Problem List includes: Type 2 Diabetes, HFrEF, Hypertension, Z59.4 (Lack of adequate food).
  • Assessment & Plan:
    • Problem 1: Food Insecurity impacting medication adherence. A: Patient is intentionally non-adherent to insulin due to food insecurity and fear of hypoglycemia. P: Provided education on hypoglycemia management. Gave patient a glucose meter and test strips. Referred patient to clinic social worker for SNAP application assistance and list of local food pantries (warm handoff completed).
    • Problem 2: Cost-related non-adherence to GDMT. A: Patient has not filled Entresto due to cost, leading to uncontrolled HFrEF. P: Submitted application to the Novartis Patient Assistance Foundation for Entresto. Provided patient with 14-day supply from clinic samples to bridge therapy. Will follow up on PAP application status in 1 week.
    • Problem 3: Uncontrolled Diabetes. A: Hyperglycemia is driven by non-adherence to insulin, which is driven by food insecurity. P: The primary intervention is to address the food insecurity. Once food access is stable, we can more safely titrate her insulin regimen. Will follow up via phone next week to assess.
  • Follow-Up: Will call patient in 1 week to check on social work connection and PAP application status. Will schedule CMM follow-up in 1 month to re-assess glycemic control once social barriers are addressed.