Improving social determinants of health means addressing the non-medical factors that shape roughly 80% of health outcomes: housing stability, food access, transportation, economic security, and social connection. These factors can be improved through targeted programs at the community, healthcare, and policy levels, and the evidence shows that even modest interventions produce measurable results in chronic disease management, hospital utilization, and healthcare costs.
Start by Identifying the Gaps
You can’t improve what you haven’t measured. The most widely used framework for assessing social needs is the PRAPARE tool, a 21-question standardized assessment that covers housing, food, utilities, employment, safety, and social isolation. A simplified version asks just three core questions: whether someone has been unable to access basic needs like housing, food, or medicine in the past year; whether they feel lonely or isolated; and whether they feel physically and emotionally safe. These questions capture the domains most strongly linked to poor health outcomes.
CMS now incentivizes this kind of screening through its Quality Payment Program. Quality Measure #487 tracks the percentage of adult patients screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. Clinicians can report this measure under the Merit-based Incentive Payment System, and CMS has identified social determinant measurement as a key priority across all its programs. If you work in a healthcare setting, building standardized screening into intake workflows is the foundation for every intervention that follows.
Stabilize Housing First
Housing is the single most impactful social determinant to address for high-need populations. Permanent supportive housing, which combines stable housing with wraparound services, has been tested in at least eight randomized controlled trials and consistently reduces emergency department and inpatient hospital use. In Virginia, state hospital utilization dropped 72.5% in the year after individuals moved into permanent supportive housing, avoiding $35.4 million in costs for that cohort alone. The costs for 168 hospitalized individuals fell from roughly $48.8 million to $13.4 million in a single year.
Housing-insecurity programs as a category return about 50% on investment, with individual programs ranging from 5% to 224% ROI. Not every housing intervention pays for itself immediately, and one study showed a negative return, but the overall trend is strongly positive. For organizations looking to justify the expense, the math works especially well for Medicaid populations, where high utilizers of emergency services generate outsized costs that stable housing directly reduces.
Treat Food Access as a Health Intervention
Food insecurity programs show the strongest financial returns among social determinant interventions, averaging 85% ROI across published studies, with some programs returning nearly three times their cost. The clinical evidence is more nuanced. A pilot randomized trial of medically tailored meals for low-income adults with type 2 diabetes found that blood sugar levels (measured by HbA1c) improved by 0.7 percentage points over six months in the group receiving meals, though a control group improved by a similar amount. The key finding: participants who actually ate more of the delivered meals saw greater improvements, suggesting that the intervention works when it changes daily eating patterns rather than simply providing food.
This points to a practical lesson. Dropping off a box of groceries is not the same as changing someone’s diet. Effective food programs pair access with education, culturally appropriate options, and meals designed around specific medical conditions. Medically tailored meal programs, produce prescription programs, and partnerships between clinics and food banks all fall under the “food is medicine” umbrella. Since January 2023, CMS guidance allows states to authorize Medicaid managed care plans to offer food-related interventions as “in lieu of” services, replacing traditional benefits. Four states already allow managed care organizations to offer specific food or housing interventions to high-need populations.
Solve the Transportation Problem
Transportation barriers cause an estimated 3.6 million Americans to miss or delay medical care each year and account for 25% or more of missed clinic appointments. This is one of the most fixable social determinants, and the evidence is clear that even simple interventions work.
A meta-analysis of seven studies found that transportation interventions reduced missed appointments by 37%, with the pooled estimate strongly favoring intervention over no intervention. The solutions don’t need to be expensive or complex. One trial found that mailing bus tickets to women who needed follow-up for abnormal cervical screening results significantly increased return rates, with 48% higher odds of completing their appointment. Taxi vouchers, ride-share partnerships, and mobile health vans all show positive effects. If you run a clinic or community health program, offering even basic transportation support can meaningfully improve care engagement.
Deploy Community Health Workers
Community health workers are trusted members of the communities they serve who bridge the gap between clinical care and daily life. They help patients navigate insurance, schedule appointments, manage medications, connect with social services, and make lifestyle changes. The evidence for their impact on chronic disease is solid, if modest in absolute terms.
In a study across two federally qualified health centers, patients who worked with community health workers showed statistically significant improvements in blood sugar control, BMI, cholesterol, and triglycerides. At one center, total cholesterol dropped nearly 12 points and triglycerides fell about 11 points after community health worker contact. At the second center, triglycerides dropped over 22 points and blood sugar control improved meaningfully. The between-group analysis, comparing patients who had community health worker contact to matched patients who didn’t, showed more modest differences, but the overall pattern was consistent: people who get help navigating the healthcare system and managing their conditions do better than those left to figure it out alone.
For healthcare organizations, community health workers are a relatively low-cost workforce investment. They extend the reach of clinical teams into patients’ homes and neighborhoods, addressing the social barriers that make chronic disease management so difficult for underserved populations.
Close the Digital Divide
Broadband internet access has become a social determinant of health in its own right. An estimated one in four Americans lacks the internet access or devices needed for video visits with a physician. Without reliable connectivity, patients can’t use telehealth, access patient portals, send messages to their care teams, or use remote monitoring devices like blood pressure cuffs that transmit readings to a clinic. During and after the COVID-19 pandemic, as health systems shifted most outpatient care to telehealth, this gap became a direct barrier to receiving basic medical attention.
Improving digital access means more than installing broadband infrastructure, though that matters enormously in rural areas. It also requires providing devices, teaching digital literacy, and designing telehealth platforms that work on smartphones with limited data plans. Libraries, community centers, and schools can serve as access points. Health systems that invested heavily in telehealth need to invest equally in making sure their most vulnerable patients can actually use it.
Build the Financial Case
The economics of social determinant interventions increasingly support investment. Across published studies where return on investment could be calculated, food programs averaged 85% ROI and housing programs averaged 50% ROI. These numbers matter because the biggest barrier to scaling social determinant programs is often not evidence of effectiveness but willingness to pay for them.
Medicaid programs are a natural proving ground. State Medicaid budgets are under constant pressure, and high-need enrollees, those with multiple chronic conditions, housing instability, and food insecurity, generate disproportionate costs through emergency department visits and hospital admissions. The CMS “in lieu of” services guidance gives states a concrete mechanism to fund social interventions through existing Medicaid managed care contracts. Social impact bonds and public-private partnerships offer additional financing models that spread risk across stakeholders while tying payments to measurable outcomes.
For community organizations, hospitals, and health plans looking to start or expand social determinant programs, the most practical path is to target the highest-cost patients first, screen them systematically, connect them to specific services (housing, food, transportation), and track both health outcomes and cost changes over time. The evidence base is strong enough to act on now, and the policy environment is increasingly supportive of doing so.