Integrating Social Determinants of Health Into Primary Care: A Team Based Population Health Approach

Disease prevention and self-management often require a team-based approach for patient-centered care. Regular follow-up with a primary care provider is important for disease prevention and the management of chronic illnesses. Social determinants of health (SDOH) impact patients’ ability to self-manage their care, and frequent contacts with the health system to reinforce treatment and prevention plans can improve outcomes. Clinicians may not have the capacity for frequent visits when they are managing large panels. Expanding the clinician’s reach with a team-based approach can provide this enhanced level of patient support.

In our health system, we have a population health referral for complex care and another for community outreach. Addressing SDOH is essential to disease prevention, as these factors influence both the onset of illness and opportunities for early intervention. Our population health team addresses SDOH and reinforces the clinician’s management plan.

As much as 50% of a person’s health outcomes are linked to SDOH.¹ These influences, including access to food, housing, transportation, employment, and level of education, all shape a person’s health outcomes. Across all of Cooper’s Southern New Jersey locations, we see patients experience the varying impacts of SDOH.

Patients with chronic conditions are often faced with attending office visits across multiple specialties, complex care plans, long medication lists, and the use of medical devices. Limited financial resources may increase a patient’s risk for negative health outcomes if they are unable to afford medications or durable medical equipment. Patients may miss or defer follow-up appointments if they cannot afford co-pays or if transportation is unreliable. These factors may limit the effectiveness of a strong clinical plan.

These impacts extend to clinicians, too. Clinicians who understand and integrate SDOH into care delivery are better positioned to enhance patient care and facilitate stronger outcomes. Olayiwola et al reported significantly lower burnout among primary care providers who perceived greater clinic capacity to address patients’ social needs.² Given the time constraints of primary care, our population health program can improve the ability of clinicians to address SDOH and likely has positive effects on clinician burnout.³

Cooper has adopted and integrated a screening and referral workflow to address social barriers in our outpatient locations. A standardized social determinant screening is part of our rooming procedures prior to a provider visit where patients are asked about any social barriers. Navigation resources are integrated in our EMR to support clinicians and team members in their conversations and are accessible through our MyChart patient portal for self-navigation as well. For example, Cooper’s resource navigation is called CooperUnite, and is powered by Findhelp.

Community Health Workers (CHW) serve as a resource for patients and clinicians alike.⁴ This peer-to-peer system is intended to assist people experiencing social barriers not easily addressed in the clinical setting. The CHWs come from the communities they serve, are knowledgeable about the system barriers patients face and use their shared background and life experiences to help address barriers to care.⁴

Together, the patient and CHW create an individualized plan for each of the goals which is carried out in future meetings.Their services may include:

• Finding community-based resources and services
• Understanding available benefits
• Improving self-support and advocacy skills
• Improving overall health and well-being

Since integrating a social determinant resource tool into our EMR approximately 5 years ago, unpublished program data from Cooper University Health Care have shown more than 50,000 people search for over 150,000 community-based resources. CHW interventions have shown the ability to improve chronic disease management by supporting patient education, connecting patients to self-management resources, and providing community-based assistance. At Cooper, when an eligible cohort of patients (n = 100) enrolled and graduated from the program, we saw a 42% reduction in ED visits and a 71% reduction in hospital admissions.

When patients are screened, referred, and connected to community-based services, they are less likely to rely on hospital-based services to address these needs. Our population health program supports our clinicians by addressing SDOH, providing longitudinal support with regular patient contact, and linking patients with CHW programs for even greater support.

References:

1. Whitman A, De Lew N, Chappel A, et al. Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2022. Accessed August 3, 2026. https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf

2. Olayiwola JN, Willard-Grace R, Dubé K, et al. Higher perceived clinic capacity to address patients' social needs associated with lower burnout in primary care providers. J Health Care Poor Underserved. 2018;29(1):415-429. doi:10.1353/hpu.2018.0028

3. Prasad K, Poplau S, Brown R, et al. Time pressure during primary care office visits: a prospective evaluation of data from the Healthy Work Place Study. J Gen Intern Med. 2020;35(2):465-472. doi:10.1007/s11606-019-05343-6

4. Knowles M, Crowley AP, Vasan A, Kangovi S. Community health worker integration with and effectiveness in health care and public health in the United States. Annu Rev Public Health. 2023;44:363-381. doi:10.1146/annurev-publhealth-071521-031648