The 5-Key Social Determinants of Health Explained for Home Care

5 Key Social Image

When admitting a patient to home health services there must be a focus of care. Although this is not changing, with value-based care on the horizon, agencies must start developing a mindset that goes beyond standard medical data collection. Agencies will need to start looking at ways to incorporate a patient’s demographics into their assessment and utilize that data to develop interventions to successfully treat patients holistically.

Social Determinants of Health (SDOH) defined

According to the World Health Organization, SDOH are the “conditions in which people are born, grow, live, work and age”. An individual’s social and economic conditions of their environment can have a major impact on a patient’s life long before they enter the healthcare system. Although addressing the focus of care is essential to improving a patient’s outcomes, it is equally important that home health providers address SDOH as part of their plan to improve health and reduce health disparities by addressing the non-medical, social needs of patients.

The 5 Key Social Determinants of Health

Below is a table containing the 5 key SDOHs to consider when performing a home health assessment, including examples of contributing social factors that may be impacting the health of a patient.

Economic Status


Social Engagement


Health Care Accessibility


Access to healthy food options


Medical Bills




Support systems


Community involvement


Childhood education

Secondary education opportunities

Language barriers

Insurance coverage

Access to medications

Cultural competency of providers

Quality care and access to information




Public safety

Water/air quality


Studies show that when a patient suffers from stresses related to the inability to afford basic needs such as food, housing, and healthcare combined with a lack of education and social isolation, their health status and life expectancy drastically decreases. It is vital that home health providers know how to identify these factors in a sensitive and HIPAA-compliant manner.

Which OASIS E items focus on SDOH?

The new OASIS data sets include items built in that help identify social determinants of health that can negatively impact a patient’s rehab potential, and an agency’s ability to improve the patient’s quality of life. 

These items include:

A1005-A1010 Ethnicity and Race

Assessing a patient’s ethnicity and race can identify patients at risk of racism or discrimination on an individual scale that can affect health and economic opportunities through negative stereotyping.   

A1110 Language

Knowing a patient’s preferred language can assist clinicians in determining how to best communicate with patients that speak and read languages other than English.

A1250 Transportation

A patient’s ability to adequately access healthcare services, social services, employment, and educational opportunities can have an impact on their overall health.   It is important as clinicians to determine if transportation is a hindrance to receiving needed care and resources.

B1300 Health Literacy

Low literacy puts a patient at risk for poor outcomes, inadequate use of preventative care, and higher emergency department use and rehospitalization rates.   If agencies tailor educational delivery to improve communication to all literacy levels, they can prevent the stigma attached to illiteracy and create communication to help patients better navigate today’s complex health care systems.  

D0700 Social Isolation

Per the World Health Organization, “the effect of social isolation and loneliness on mortality is comparable to that of other well-established risk factors such as smoking, obesity, and physical inactivity.”  Identifying and addressing these risk factors during assessment can drastically improve patient outcomes and health.

SDOH Documentation and Interventions

Step 1 SDOH Data Collection and Documentation

Administrators of home health agencies should provide training to support SDOH data collection. These assessments can be sensitive in nature and clinicians should approach the necessary line of questioning in a way that builds patient/caregiver trust and conveys a goal of patient advocacy. Geographical location can influence the needs of the community or population. More rural agencies may have vastly different localized SDOH concerns than an urban agency. Each agency will need to identify what they feel their biggest SDOH concerns are. Once relevant SDOH concerns are identified, a decision must be made regarding an internal policy and how to consistently document standardized SDOH data in the EMR. Sharing this workflow with the all staff will result in improved coordination and referrals.

Step 2 Implementing Social Needs Interventions

Once an SDOH focus is established for an agency, then steps can be taken to decide how identified concerns will be addressed. Encouraging clinical staff to reach out to physicians and request a Medical Social Worker evaluation is always a good first intervention. If an agency does not have an MSW on staff, next best steps would include educating clinicians on what social service organizations as well as appropriate support services are available through local, state and national resources. An agency can then collaborate to decide who will be responsible for making those referrals. Another option may be to provide easy to understand brochures or pamphlets, and assist patients with low literacy levels in reaching out to utilize helpful services.Keep in mind that any member of a person’s care team can collect SDOH data, so education regarding SDOH should not be limited to clinical staff. Agencies should also consider providing education for marketing staff, intake, and any other individual that may have patient interactions.

Step 3 Monitoring SDOH Intervention Effectiveness

As many agencies are starting their transition into OASIS-E and HHVBP, they are putting new initiatives in place to track SDOH risks across their patient population to improve patient care and outcomes. One such way that some agencies will be identifying and collaborating about these at-risk patients will be to set aside time at their case conferences to discuss these patients and their concerns. This time can be utilized to identify patients with unmet social needs and possibly trigger referrals. 

Tracking input from various disciplines involved in a patient’s care can help determine next steps to helping a patient get the resources that may be needed. Many agencies are addressing SDOH concerns by tracking specific Z codes that indicate a patient is at risk. These Z code categories include, but are not limited to:

  • Z55 – Problems related to education and literacy
  • Z56 – Problems related to employment and unemployment
  • Z57 – Occupational exposure to risk factors
  • Z58 – Problems related to physical environment
  • Z59 – Problems related to housing and economic circumstances

This list of ICD-10 categories represent factors influencing health status and contact with health services. It is imperative that clinicians know that these factors can be coded based on self-reported data and/or information documented by any member of the care team if their documentation is included in the official medical record. If clinicians do not document the risk, a Z code is likely to not be assigned, which means collaboration and tracking will stop there and a patient may miss out on receiving an intervention that drastically improves their care.

Everyone is a patient advocate

Although there has been significant progress recognizing and addressing social determinants of health, many challenges remain. Leveraging demographic and economic data is the foundation for addressing social determinants, but most organizations are working with an incomplete picture at best. Everyone that interacts with a patient can ultimately serve as a patient advocate and play a role in improving their quality of life. 

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