Blog Post

Kidney Disease Management: Screening for Social Determinants of Health


Addressing social determinants of health (SDoH) is a major challenge for healthcare providers. Healthmap can help!



One of the major challenges in kidney disease management lies in identifying and addressing the non-medical factors that influence health outcomes, known as social determinants of health (SDoH). SDoH factors include:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities, and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality

According to the World Health Organization: [1]

“Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDoH accounts for 30%-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.”

“Addressing SDoH appropriately is fundamental for improving health and reducing long-standing inequities in health ...”

The accountable care models coming from the Centers for Medicare and Medicaid Services (CMS) and the recognition of care inequities by both the healthcare community and larger society are creating a demand for SDoH screenings, starting at the primary care level. But this brings up its own set of challenges.

From an article published on the American Academy of Family Physicians (AAFP) website, “A Practical Approach to Screening for Social Determinants of Health”: [2] 

“Physicians should note that screening for social determinants is intrinsically different from traditional screening for medical problems. Both, however, require that screening occurs in a setting where the appropriate referral or linkage to resources to address an identified need can take place. To do otherwise would be ineffective and unethical. Discovering a need and being ill-equipped to address that need creates potential harm for the patient and frustration and burnout for the physician. To avoid these unintended consequences and make screening an invaluable part of the clinical process, practices need to ensure that screening is patient- and family-centered, integrated with referrals to community-based resources, comprehensive across all patient populations, and focused on leveraging the strengths of patients, families, and communities.”

Screening Tools

Though a number of SDoH screening tools have been developed, there is no single preferred tool. The AAFP article suggests the following:

  • The PRAPARE tool [3] (“Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences”) is used by the National Association of Community Health Centers and several other organizations. It collects demographic information and assesses a patient for a host of social needs, including housing, employment, education, security, transportation, and stress. The data can be directly uploaded into many electronic health records. It is generally administered by clinical or nonclinical staff, but patients can also self-administer.
  • AAFP offers a SDoH screening tool as part of The EveryONE Project [4]. It is a short survey of 11 questions about housing, food, transportation, utilities, personal safety, and the need for assistance. It is available in Spanish and can be self-administered.
  • CMS’s Accountable Health Communities project [5] developed a 10-question Health-Related Social Needs screening tool (the AHC-HRSN) that is meant to be self-administered. It draws on evidence from other validated assessments that address specific unmet social and material needs.

One of the basic challenges with SDoH identification is finding the time for screening. Physicians are already stretched to the limit. Research has shown that the average Primary Care Physician (PCP) needs 27 hours a day just to provide basic care to an average number of patients. The time needed to screen for SDoH and to research resources available to address them may simply not be available.

Healthmap Solutions’ Answer

Addressing treatment shortfalls due to SDoH issues is essential to improving chronic kidney disease and end-stage renal disease outcomes for disadvantaged patient populations. This is an area where Healthmap is already assisting providers.

Our Care Navigators (CNs) work directly with patients to engage and empower them in their disease management journey. We talk about this in our recent blog post, “The Patient Journey: The Care Navigator’s Perspective.” [6]

When interacting with their patients, Healthmap CNs will gently probe to uncover SDoH issues. They then work to connect patients with the needed resources to address their particular needs.

For example, in the blog, one of our most experienced CNs tells us that in her first contact with a patient, “I like to mention that we have other services available to help. I point out that we offer transportation services to get them to their doctor’s office or to have labs drawn, for example. If the issue is food insecurity, I can provide guidance to local food banks and churches to offer support.”

Identifying and addressing SDoH issues is an intrinsic part of Healthmap’s Kidney Health Management program. It is one of the important ways we support our provider partners to help support their patients’ needs.

We Are Committed to improving kidney disease outcomes for everyone! We Are Healthmap!


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