Humana is committed to promoting integrated care delivery and value-based models to improve healthcare delivery and outcomes.

Painting a Bigger Picture of Patient Well-Being: Opportunities and Challenges in Screening for Social Determinants of Health

Health happens continuously, 365 days a year, in every area of a patient’s life — most of which is outside of the doctor’s office.

Despite the development of multiple, standardized means for screening patients for social determinants of health (SDoH), leaders with health care practices across the country still spend significant time trying to decide which factors to include in such screenings, according to a new report by the Medical Group Management Association (MGMA) in partnership with Humana.

The report, “Painting a Bigger Picture of Patient Well-Being: Opportunities and Challenges in Screening for Social Determinants of Health,” found that SDoH screenings can be personal and include information patients may not relate to their health or may not want to share, oftentimes turning into case-by-case interactions without static, consistent evaluation criteria.

The report shares examples of how practices honing their efforts can:

  • Develop an appropriate SDoH screener for patients. Most practices surveyed – 59% – rely on nurses and medical assistants to conduct screenings.
  • Implement screeners into the practice’s workflows. While 61% of practices screen through electronic health records systems, many (16%) still obtain information via paper-based methods.
  • Communicate and engage with their patients to capture accurate data. Adequate training adequately can help staff effectively communicate why accurate SDoH information is important for the practice’s ability to provide better care for the patient.


Spotlighted practices, including some that see Humana-covered patients, weigh in on how they’ve overcome challenges in operationalizing SDoH screenings and where opportunities exist.

“We are able to successfully adapt and craft quick solutions to address the clinical and social needs of our most vulnerable members,” said Caraline Coats, Vice President, Bold Goal and Population Health Strategy. “We are at a time when our work has not mattered more. What we do, who we serve and how we can make a difference are all top of mind every day.”

Some medical practices began their work in SDoH by addressing a specific issue they noticed in their patient population. For example, Hatfield Medical Group in Arizona piloted a program to address patients who did not have adequate transportation and would miss appointments.

“We didn’t call it social determinants of health back then,” said Jim Schafer, vice president of health services at Hatfield. “We just called it, ‘the patient needs to be here.’ We just want to ensure access to care. How do we overcome this barrier? (Patients) need to be able to see their provider.”

Whether a medical group practice is dealing with patient transportation needs or the effects associated with homelessness, food insecurity, domestic violence or other matters, recognizing issues facing patients is a starting point for determining how to gather data from them, according to the report.

Humana routinely partners with professional organizations such as the MGMA on research to obtain important health care provider perspectives and guidance about topics relevant to their practices and patients. 

To download and view the full SDoH report, click here.

You might also like