Social Determinants Of Health Resources

Given that 80-90% of health determinants occur outside of the doctor’s office, clinical care alone is insufficient. That’s where social determinants of health (SDOH) resources come into play—giving healthcare providers, public health agencies, and community organizations the tools they need to identify and address non-medical factors influencing patient outcomes.

Integrating SDOH screening into practice, locating data for grant applications, or accessing training materials requires familiarity with available resources. Federal agencies, research institutions, and community organizations have developed extensive resource libraries over the past decade. Efficient navigation of these resources depends on understanding their scope and location.

This guide walks you through major SDOH resource hubs, clinical screening tools, community data sources, and educational materials to help you address social determinants in your work.

What are social determinants of health (SDOH)?

Social determinants of health are the non-medical conditions in which people are born, live, learn, work, play, and age that shape health outcomes. These factors—often called “upstream” influences—affect health long before someone walks into a clinic or hospital. Understanding them is essential for anyone working in public health, clinical care, or community health promotion.

The five SDOH domains

The World Health Organization and the U.S. Centers for Disease Control and Prevention (CDC) organize social determinants of health into five interconnected domains:

Domain	What It Includes	Real-World Examples
Economic Stability	Income, employment, expenses, debt	Job loss leading to missed medications
Education Access and Quality	Literacy, early childhood education, and higher education	Limited health literacy affects treatment adherence
Health Care Access and Quality	Insurance coverage, provider availability	Lack of nearby community health centers
Neighborhood and Built Environment	Housing, transportation, safety, food access	Living in a food desert with no grocery stores
Social and Community Context	Social support, discrimination, civic participation	Social isolation increases depression risk

Food insecurity, for example, doesn’t just mean going hungry—it means limited access to nutritious foods that prevent chronic disease. Safe housing isn’t just about having a roof overhead; it’s about avoiding the mold, pests, and temperature extremes that trigger asthma attacks and worsen heart disease.

How much do SDOH actually matter?

Research consistently shows that social determinants account for 30-55% of health outcomes, depending on the population and methodology. The World Health Organization emphasizes that health follows a stark social gradient: at every income level, those with lower socioeconomic status face higher risks of illness and mortality. The CDC positions these factors as central to health equity, noting that medical care accounts for only 10-20% of modifiable contributors to health.

The practical implications are significant. Lack of access to healthy foods, safe housing, and reliable transportation directly increases risks for chronic conditions like diabetes, heart disease, and asthma. When someone can’t afford their heating bill, they’re not just cold—they’re at higher risk for respiratory infections and cardiovascular events.

SDOH resources help clinicians identify patients facing housing instability or food access challenges during routine visits. Public health organizations use these resources to target interventions at the neighborhood level, where health risks are concentrated. Community groups leverage SDOH data to advocate for policy changes that create social and economic environments supporting well-being.

Key U.S. federal SDOH initiatives and resource hubs

Multiple U.S. federal agencies maintain dedicated, free online SDOH resource hubs. These portals consolidate tools, data, policy guidance, and implementation support that health systems, public health departments, and community organizations can access without cost. Knowing which agency offers what can save hours of searching.

Healthy People 2030

Launched in August 2020 by the Office of Disease Prevention and Health Promotion, Healthy People 2030 serves as the national framework for improving health across the population. It includes a dedicated SDOH domain with measurable objectives to reduce health disparities and achieve health equity through 2030.

The framework sets specific, trackable targets across all five SDOH domains. Many objectives highlight connections between economic stability, education, and health outcomes that traditional healthcare research often overlooks.

HHS Social Determinants of Health Hub

The HHS SDOH Hub serves as a central portal linking to SDOH tools, data, and policy guidance from agencies such as the Centers for Medicare & Medicaid Services (CMS), the Health Resources & Services Administration (HRSA), the CDC, and the Agency for Healthcare Research and Quality (AHRQ). It’s beneficial for finding cross-agency reports and strategy documents that emerged between 2021 and 2023 addressing SDOH integration into health and human services delivery.

CMS Accountable Health Communities Model

The Accountable Health Communities (AHC) Model, which ran from 2017-2022, tested SDOH screening and community service navigation for beneficiaries of Medicare and Medicaid. While the formal demonstration has concluded, the resources developed—including standardized screening tools and referral protocols—remain freely available and widely adopted by health systems nationwide.

HRSA Bureau of Primary Health Care

The HRSA SDOH resources page specifically supports Federally Qualified Health Centers with screening protocols, referral workflows, and training materials. Community health centers serving underserved populations can find continuing education opportunities, sample policies, and implementation guides tailored to primary care settings.

Healthy People 2030 and SDOH-focused tools

Healthy People 2030 represents the fifth decade-long national health plan, with an explicit focus on “upstream” SDOH to advance health equity. Unlike previous iterations, this version positions social determinants as foundational rather than supplementary, recognizing that clinical interventions alone cannot address persistent health disparities.

SDOH objectives and domains

SDOH serves as one of the five overarching Healthy People 2030 topics. The framework contains over a dozen core objectives, including:

• SDOH-01: Reduce the proportion of people living in poverty

• SDOH-02: Increase employment in working-age people

• SDOH-03: Reduce the proportion of families spending more than 30% of income on housing

• Objectives specifically related to incarceration, educational attainment, and food security

Each objective includes baseline data, target values, and data sources for tracking progress. The objectives related to food access, housing stability, and educational attainment connect directly to outcomes tracked in minority health and disease control metrics.

Literature summaries and evidence resources

Healthy People 2030 provides SDOH literature summaries for domains such as education access, transportation, incarceration, and economic stability. These summaries synthesize current evidence on how each factor influences health outcomes and were reviewed or refreshed around 2023-2024 to incorporate emerging research.

Public health planners can use Healthy People 2030 SDOH objectives directly in local community health improvement plans. The framework aligns with accreditation standards, making it straightforward to demonstrate how local initiatives help achieve national targets.

Downloadable resources

The platform offers downloadable data tables, charts, and links to evidence-based resources to support reports and grant applications. Links to The Community Guide provide access to systematic reviews of community-based interventions addressing SDOH, helping organizations identify strategies with demonstrated effectiveness.

Major federal SDOH resource collections

Several federal agencies maintain curated collections of SDOH tools, reports, and case studies with distinct but complementary focuses. Understanding these differences helps you find what you need faster.

CDC Public Health Infrastructure Center

The CDC SDOH resources focus on supporting state, tribal, local, and territorial health departments. Key frameworks include:

• Pathways to Population Health Equity (P2PHE): A strategic framework for integrating equity across public health practice

• Community Health Assessment Tools: Templates and guidance for conducting assessments that capture SDOH alongside traditional health indicators

• 10 Essential Public Health Services Integration: Resources showing how to embed SDOH considerations into each essential service

CDC’s pages often include implementation guides, funding examples, and training materials. The focus on population health approaches makes these resources particularly valuable for health departments working on community-wide interventions rather than individual patient care.

AHRQ Health Services Research Resources

AHRQ’s SDOH resources emphasize healthcare research, quality improvement, and practice transformation. The focus here is on clinical or nonclinical staff integrating SDOH screening and referrals into routine visits.

Key AHRQ resources include:

• Primary care practice guides for SDOH screening workflows

• Quality measures incorporating social needs

• Research findings on effective referral and navigation models

• Tools for structured data collection within electronic health records

AHRQ materials tend toward implementation science—practical guidance on how to make SDOH integration work in real clinical settings.

Health and Human Services(HHS) Cross-Agency Resources

Beyond Healthy People 2030, HHS maintains overarching SDOH resources, including equity action frameworks published between 2021 and 2023, cross-agency strategy documents, and data dashboards. These resources address improving health outcomes at the systems level, connecting clinical care delivery with community-based services through partner organizations and coordinated approaches.

Clinical SDOH screening tools and implementation resources

Health systems increasingly use standardized SDOH or health-related social needs screening tools to identify patients facing non-medical challenges. Multiple publicly available tools exist, each with different domains, question lengths, and administration methods.

Major screening tools

Several validated screening tools have emerged between 2014 and 2020:

Tool	Developer	Key Features
PRAPARE	NACHC	21 core questions, optional supplemental questions, designed for community health centers
AHC HRSN Screening Tool	CMS	10 core questions, developed for Medicare/Medicaid populations, generally administered by clinical or nonclinical staff
AAFP Social Needs Screening Tool	American Academy of Family Physicians	Shorter format for family physicians, integrates with practice workflows

These tools typically cover housing, food, utilities, transportation, interpersonal safety, employment, education, social supports, and legal needs. The domains align with recommendations from the National Academy of Medicine (formerly the Institute of Medicine) for core social domains to be captured in electronic health records.

Administration and settings

Peer-reviewed rapid reviews published between 2018 and 2022 summarize findings across 8-10 common SDOH screening tools. Key findings include:

• Tools can be self-administered via tablets or a paper version, or administered by medical assistants, nurses, or community health workers

• Primary care, pediatrics, and emergency departments have successfully implemented screening

• Question length ranges from 5-6 items (brief screens) to 21+ items (comprehensive assessments)

• Many electronic health records now support structured data capture from these screeners, with results directly uploaded into patient records

Implementation support

Effective implementation requires more than selecting a tool. PRAPARE and the CMS AHC tools include implementation support resources such as:

• Sample workflows showing when and how to screen

• EHR integration guides for health systems using Epic, Cerner, or other platforms

• Referral mapping templates connecting positive screens to local services

• Training materials for clinical and nonclinical staff

Successful programs invest in staff training, patient-centered scripting (explaining why you’re asking about housing or food access), clear referral pathways to community resources, and tracking outcomes over time. Without these elements, screening can identify needs but not improve health outcomes.

Community, public health, and data resources for SDOH

SDOH resources extend well beyond clinical settings, including community planning tools, assessment frameworks, and open-access data that inform policy decisions. These resources help translate SDOH concepts into action at the neighborhood and community level.

Assessment frameworks

Local health departments commonly use established frameworks to integrate SDOH and health equity into community health improvement planning:

• MAPP (Mobilizing for Action through Planning and Partnerships): A strategic planning process guiding communities through comprehensive assessment and action planning

• CHANGE (Community Health Assessment and Group Evaluation): CDC’s tool for evaluating community health status and organizational policies

Both frameworks emphasize community engagement and data-driven prioritization of SDOH-related issues.

Data tools

Several data tools provide neighborhood-level SDOH indicators:

CDC/ATSDR Social Vulnerability Index (SVI): Updated regularly (2018, 2020, 2022 releases), SVI ranks census tracts based on 16 social factors grouped into four themes: socioeconomic status, household characteristics, racial/ethnic minority status, and housing type/transportation. Health departments use SVI to identify communities that require additional support during emergencies or in resource allocation decisions.

County Health Rankings & Roadmaps: Published annually since 2010, this tool provides county-level data on health outcomes and health factors, including extensive SDOH indicators. The site includes “What Works for Health” resources identifying evidence-based policies and programs.

Community resource directories

Connecting screened patients to local services requires knowing what’s available. Resource directories include:

• 2-1-1 networks: State and local information lines connecting callers to health and human services

• Unite Us: Closed-loop referral platform connecting health systems with community-based organizations

• Aunt Bertha/FindHelp: Searchable database of local services by zip code

These tools help address SDOH by linking identified social needs to specific community resources.

Real-world application

During the COVID-19 vaccine rollout in 2021, many city health departments used SVI data to prioritize outreach in neighborhoods with high social vulnerability scores. By identifying areas with transportation barriers, limited internet access, and high proportions of essential workers, public health organizations could target mobile vaccination clinics and door-to-door campaigns where they’d have the greatest impact on reducing health disparities and achieving better outcomes.

Infographics, education materials, and SDOH resources for older adults

Visual and age-specific health resources make SDOH concepts more accessible to the public and to professionals working with older adults. These materials translate complex frameworks into practical, actionable formats suitable for diverse audiences with varying levels of health literacy.

Federal and nonprofit infographics

Multiple agencies have produced SDOH infographics focusing on each of the five domains. Many were updated or created between 2020 and 2024 to support equity messaging and COVID-19 response communications. These materials typically:

• Use simple language and visual elements

• Are downloadable as PDFs for printing or digital sharing

• Include data points illustrating SDOH impacts

• Connect to longer resources for those wanting deeper information

Healthy People 2030, CDC, and AHRQ host printable fact sheets and infographic-style summaries that show how factors such as transportation, social isolation, and housing affect older adults’ health and functional status. These can serve as conversation starters with patients or community members unfamiliar with SDOH concepts.

SDOH and aging resources

Older adults face distinct SDOH challenges, including social isolation, fixed incomes, housing accessibility needs, and transportation limitations. Several agencies provide targeted resources:

Administration for Community Living (ACL): Resources addressing food access, home safety, caregiver support, and social engagement for older adults

Area Agencies on Aging: Local agencies often provide practical checklists and assessment tools for home visits, addressing fall risks, medication management, and access to meals

National Association of Area Agencies on Aging: Toolkits for community organizations working to address sdoh data collection and intervention with older populations

Using materials in practice

Clinicians, social workers, and community health workers can use these materials in:

• Waiting rooms: Posters and brochures introducing SDOH concepts before appointments

• Workshops: Visual aids for group education sessions on healthy aging

• Home visits: Checklists helping identify environmental and social risk factors

• Caregiver training: Educational materials explaining how social conditions affect their loved one’s health

User-friendly SDOH resources—infographics, one-page guides, and short videos—are critical for outreach among older adults and communities with limited health literacy. These materials bridge the gap between research evidence and practical understanding, making the importance of addressing health-related social needs tangible and actionable.

Key takeaways

• SDOH resources span federal agencies (CDC, AHRQ, HHS, HRSA, CMS), each with distinct focuses from clinical implementation to community planning

• Healthy People 2030 provides a national framework with measurable SDOH objectives and downloadable resources for local adaptation

• Clinical screening tools like PRAPARE and the AHC HRSN tool offer standardized approaches, with many electronic health records supporting integration

• Community data tools (SVI, County Health Rankings) enable neighborhood-level targeting of interventions

• Age-specific and visual resources help translate SDOH concepts for diverse audiences, including older adults

Conclusion

The resources available to address social determinants of health have expanded dramatically over the past decade. From clinical screening tools that integrate with electronic health records to community data platforms informing policy decisions, organizations at every level now have access to evidence-based frameworks and practical implementation support.

Start by identifying which SDOH resources align with your organization’s current priorities. If you’re implementing screening in primary care, the PRAPARE tool and AHRQ implementation guides offer a clear starting point. If you’re planning community health improvement initiatives, Healthy People 2030 objectives and County Health Rankings data provide the foundation.

The gap between identifying social needs and actually improving health outcomes remains the central challenge. These health resources provide the infrastructure—but closing that gap requires sustained commitment to training, workflow integration, and community partnerships that connect clinical care to the social and economic environments where health is actually made.

Bookmark the key resource pages mentioned here, share them with your team, and identify one concrete step you can take this month to better address social determinants in your work.