CHICAGO — Health equity is about fair and just care for everyone, and there’s no quality in healthcare without equity, Jillian Rose-Smith, PhD, MPH, MSW, vice president and chief equity officer at Hospital for Special Surgery in New York City, told attendees at American College of Rheumatology (ACR) 2025 Annual Meeting. Rose-Smith reviewed policy directives related to social determinants of health (SDOH) in the past few years, upcoming shifts in policy, and how healthcare providers can not only collect meaningful data about these determinants but also leverage it to deliver better care to all patients.

“Health equity continues to be a worthwhile and noble cause in healthcare...and as we take a look at our national landscape and all the conversations we’re going to have, social determinants of health are really key to our conversation,” Rose-Smith said. “If we really are serious about making changes in population health and the quality of care and the outcomes of our patients, we have to pay attention to where they live, work, and play and how we influence those spaces.”

Rose-Smith further noted how urgent some of these needs are about to be right now. “In 1 week, millions of Americans will lose their food benefit if the government continues to be shut down,” she said. “That’s a social determinants of health need that you will have to contend with.”

While she spent much of the presentation discussing the challenges and barriers to integrating SDOH information into clinical care and following up on referrals to community services, Rose-Smith also highlighted how even casual conversation during appointments can enable providers to help patients when they simply talk to them, outside of the forms they fill out.

“We can use our humanity to leverage care outcomes, and that’s really our superpower,” she said. Ask patients how things are going, what their needs are, how their family is, how they arrived at the clinic that day, how their home is — find out what’s going on in their lives, she said. “Sometimes asking those questions will lead you to answers to uncover things in people’s lives that are really plaguing them and that you can help to make a difference.”

Suzan Fischbein, LCSW, of Hillsdale, New Jersey, said the presentation was wonderful and highlighted the value of integrating SDOH into clinical care.

“When we talk about these issues, it’s very often thought that there isn’t enough time to do that,” she said. “But in the long run, and I’m sure if we studied this, we would find this: It actually saves time, and it also optimizes the care and builds the relationship between the provider and the patient.”

Understanding the Shifting Policy Landscape

Multiple federal regulations now focus on the need for clinicians and healthcare facilities to collect data on the social needs of patients. The Centers for Medicare & Medicaid Services (CMS) began reimbursing practitioners for risk assessment of SDOH in January 2024 when clinicians use standardized, evidence-based tools, such as the Accountable Health Communities Health-Related Social Needs Screening Tool and the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences. These tools assess five key areas — food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety — and clinicians can then document any identified social needs in patients’ medical records. Also since 2024, hospitals are required to report how many inpatients are screened for health-related social needs and the screen positive rate for those with at least one need in any of the five areas. Although data collection is currently only encouraged for outpatient care, there are proposals for making it mandatory next year.

At the same time, though, there is a potential upcoming regulatory shift that, because of the administrative burden of collecting and documenting these data, will move away from SDOH data capture in inpatients toward measuring clinical outcomes instead.

“Many of us have been shielded from having to pull out this information in any systemic way in our EHR [electronic health record], and now CMS is proposing mandatory outpatient SDOH reporting in 2026 to capture social risk across care settings, so we’re moving from inpatient mandatories in place right now to outpatient mandatory collection,” Rose-Smith said. The rule would rebalance SDOH policy with a new focus on prevention, outcome correlation, more outpatient data integration, and more automated, targeted approaches to advance health equity rather than manual screening. Clinicians therefore need to be prepared for this shift and have a plan for it in their outpatient settings.

Disparities Persist

In the midst of this shift, disparities persist, Rose-Smith said. About 1 in 3 Americans have low health literacy, 3.6 million Americans have transportation challenges that prevent them from receiving medical care each year, and research shows that SDOH can account for 80%-90% of adverse health outcomes.

With lupus, for example, a 2023 study found a substantial impact from SDOH on the disparities seen in lupus. The researchers found worse disease and psychosocial outcomes associated with lower income, lower education levels, disadvantaged neighborhoods, lack of health insurance, travel burden, anti-Black racism, and lower social support — and that improving patients’ management and outcomes will require addressing the underlying causes of those inequities.

In another study on rheumatoid arthritis this year, researchers found that with each additional SDOH a patient had increased their all-cause mortality risk by 24% and their cardiovascular mortality by 25%. Patients with at least five adverse SDOH had nearly four times the mortality risk for patients with none, particularly with unemployment, low income, less than a high school education, and being unmarried. Again, the authors concluded that addressing SDOH through targeted public health policies, social support, and access to quality care could improve health equity and long-term outcomes.

Translating Data Collection Into Action

The good news is that increased screening for SDOH is occurring, largely because of the CMS mandate requiring healthcare centers to begin collecting that data, and healthcare team buy-in already exists about the value of understanding patients’ social circumstances. The problem is helping clinicians and systems use that data to address patients’ needs and improve care and outcomes.

“The inability to use these data effectively can foster mistrust and frustrate patients and healthcare workers, reducing the potential for a positive impact on health outcomes,” Rose-Smith said.

In a March 2024 study, for example, over two thirds (68.5%) of 563 US healthcare providers agreed that SDOH affect all patients’ outcomes, but less than a quarter (24.1%) said their setting is equipped to address SDOH. Nearly half (48.6%) screen for SDOH, but a majority of respondents (55.7%) wanted additional resources to focus on SDOH. Barriers included limited workforce capacity, time, training, and payment models for nonclinical services as well as concerns about patient discomfort with screening and not being able to refer patients to social services.

Similar results on successful collection and recording of data appeared in a February 2023 report from the American Health Information Management Association (AHIMA) and National Opinion Research Center at the University of Chicago on the collection, integration, and use of SDOH. The AHIMA surveyed its member organizations, and among 2637 respondents, nearly 8 in 10 organizations (78%) reported collecting SDOH data, and 71% said they’re recording and coding it.

But far fewer were integrating the data into EHRs. For example, 91% reported collecting data on health behaviors and mental health, but only 61% and 62%, respectively, integrate it into their EHRs. Similarly, 80% collect data on homelessness, but barely half (53%) integrate it into EHRs. The story was similar for collecting and using data on language (80% vs 57%) and social isolation (78% vs 50%). Without actual integration into the EHR, providers cannot get reimbursement. Another gap was follow-up with patients. While 82% of organizations reported making electronic referrals to community-based organizations, only 64% have closed-loop referral systems that allow them to track outcomes.

Rose-Smith acknowledged the practice realities that make it difficult to gather and use SDOH in clinical care, including time constraints in busy rheumatology clinics, lack of training or discomfort in discussing sensitive social issues, and a perceived misalignment with providers’ “medical” responsibilities. At the system level, there are limited resources for identifying patients’ needs, inconsistent EHR integration of screening tools, and fragmented referral and follow-up pathways. There are also challenges around patient communication, including distrust from patients in disclosing their social challenges, language and cultural barriers, and stigma associated to certain needs, such as housing instability and food insecurity.

Studies have shown, however, that SDOH data collection is feasible in rheumatology practice. “Some of this work we think of being outside of our wheelhouse, but it’s aligned with the work that we need to do,” and it’s within clinicians’ scope of influence, Rose-Smith said. She outlined how to bridge policy and practice in four key areas:

• Workflow alignment that involves embedding screening into existing clinical processes and automating EHR prompts to standardize collection of SDOH data
• A team-based approach that enables physicians to identify needs and send that to social workers, patient navigators, and care coordinators to follow up, so that the shared responsibility avoids overburdening clinicians
• Resource mapping that builds and updates a directory of local and community resources and involves establishing partnerships with food banks, transportation programs, and housing organizations
• Closing the loop by developing processes for follow-up after referral and tracking whether patients accessed the services and got their needs met

Rose-Smith emphasized that it’s possible to start small and work on these issues a little at a time. “It’s important for us to start somewhere,” she said. For example, instead of taking several hours to try to come up with a list of community resources, instead take 10 minutes next week to list two community organizations that may help with patient needs. Then, do the same the following week and continue that, and “you will have built a local directory of resources that will be beneficial to your patients,” she said.

Rose-Smith recommended talking with healthcare systems to strengthen data interoperability so that the burden of screening — which is likely already occurring at a system level — is not on providers.

“Collection of SDOH without providing adequate follow-up and support can damage partnerships,” she said. “Identify and build collaborative partnerships with expert in healthcare information technology, digital platforms, and artificial intelligence to streamline processes and automate referrals.” A teamwork approach at all levels can reduce the burden on providers while finding ways to use the SDOH information collected to actually help patients and subsequently improve outcomes.

The presentation did not use external funding, and Rose-Smith and Fischbein had no disclosures.

Tara Haelle is a science/health journalist based in Dallas.