What Are Social Determinants of Health?
When we think of what determines our health, we often focus on doctors, medications, and hospital visits. But decades of research in public health and community health assessment show that the majority of health outcomes are shaped not in exam rooms—but in our neighborhoods, homes, workplaces, and schools.
These influential, nonmedical factors are called Social Determinants of Health (SDOH)—and they are the hidden drivers behind health inequities, premature mortality, and preventable hospitalizations across the United States. For an in-depth exploration, visit our complete guide on Social Determinants of Health and their impact on equity. They help explain why two people with the same diagnosis can experience vastly different outcomes, and why simply expanding insurance coverage isn’t enough to close the gaps in life expectancy, chronic illness, or mental wellness. Want to see how these factors play out in real life? Browse through real-world examples of these determinants that show how non-medical barriers impact patient outcomes.
At Presidium Health, we believe addressing social determinants is essential to achieving whole-person care. It’s not just about treating illness—it’s about health promotion, prevention, and meeting basic needs at every stage of life.
According to the World Health Organization, Healthy People 2030, and resources from nearly every major government website on public health, SDOH are grouped into five core domains:
Economic Stability
Economic stability is a core Social Determinant of Health because it directly affects a person’s ability to access basic needs like housing, food, healthcare, and transportation. Without stable income or employment, individuals are more likely to face food insecurity, housing instability, poor access to medical care, and chronic stress—all of which contribute to worse health outcomes. Economic hardship also creates a cycle where poor health makes it harder to maintain work, deepening long-term instability. In short, economic stability lays the financial and structural foundation for good health.
Education Access and Quality
Education access and quality is a powerful force behind lifelong health and well-being. Education helps people understand their health, make informed decisions, and confidently navigate the healthcare system. It shapes how individuals approach nutrition, physical activity, mental health, and preventive care. Early learning experiences, supportive schools, and strong literacy skills all contribute to healthier lives—mentally, emotionally, and physically. When people have access to high-quality education, they’re more empowered to care for themselves and their families. Without it, entire communities face greater risks of illness, stress, and missed opportunities to thrive.
Health Care Access and Quality
Health Care Access and Quality shapes every stage of a person’s health journey—from prevention to treatment to long-term well-being. It’s not just about having a doctor nearby; it’s about whether people can actually reach care that is timely, affordable, culturally responsive, and effective. Healthcare access is a crucial social determinant of health, significantly influencing individual well-being and overall community health outcomes by determining the availability and quality of medical services. This includes having access to comprehensive health insurance, trusted providers, and services that meet linguistic, geographic, and emotional needs. When care is delayed, inconsistent, or absent altogether, manageable conditions can escalate into life-threatening ones. Quality health care builds trust, supports early detection, improves health literacy, and reduces avoidable hospitalizations. Conversely, barriers to care—like provider shortages, high costs, discrimination, or limited transportation—contribute to chronic illness, premature death, and deepening health disparities. Ensuring access to high-quality care is not just a clinical concern—it’s essential to advancing health equity and community resilience.
Neighborhood and Built Environment
Where people live directly impacts how well they live. Safe housing, clean air and water, access to healthy food, and proximity to medical care all shape health outcomes.
Walkable neighborhoods with sidewalks, lighting, and bike lanes promote daily physical activity, reduce isolation, and improve mental and physical health. They allow residents—especially seniors, children, and those without cars—to safely access schools, clinics, and community resources. When paired with accessible public transportation, communities become even more connected. Reliable transit systems help people get to jobs, medical appointments, and grocery stores—essentials for long-term health and independence.
Environmental quality plays a major role. Clean air and water are foundational to good health—yet many low-income communities are disproportionately exposed to pollution, industrial waste, unsafe drinking water, and other environmental hazards. These exposures are linked to higher rates of asthma, cancer, and developmental issues in children.
Social and Community Context
The strength of our social ties, sense of belonging, and ability to engage in our communities directly impact how we manage stress, recover from illness, and access vital resources. Supportive relationships and inclusive communities foster resilience, encourage healthier choices, and reduce the risk of mental health challenges. In contrast, social isolation, discrimination, and chronic exposure to inequity can elevate stress hormones, increase the likelihood of chronic disease, and erode trust in healthcare systems. Environments marked by safety, respect, and participation—where people feel valued and empowered—are essential to achieving health equity. Ultimately, our social surroundings shape how safe we feel, how much support we have, and whether we are able to live with dignity and purpose. Health is not just shaped in clinics or hospitals—it is cultivated through connection, justice, and community.
”The System Was Never Built For Whole-Person Care—It Was Built For Billing. That’s Why It Overlooks Hunger, Housing, And Human Pain. At Presidium Health, We’re Not Tweaking A Broken Blueprint—We’re Rewriting It, With Dignity, Equity, And Lived Reality At The Center. Real Health Starts With Real Life.
-Pouya Afshar, MD
The Real Stories and Measurable Impact of Social Determinants of Health
| Lived Experience (Real Stories) | Associated SDOH Domain | Data-Driven Impact |
|---|---|---|
| A man with diabetes is hospitalized because he couldn’t refrigerate his insulin due to unstable housing. | Housing Instability | Housing insecurity is linked to nearly 2x higher rates of poor health. People experiencing homelessness have a life expectancy 17.5 years shorter than the general population. |
| A senior woman misses her primary care visits because there’s no public transit near her home. | Transportation & Built Environment | Access to transportation is a critical determinant of healthcare access. Life expectancy can vary by up to 30 years between ZIP codes due to environmental and infrastructure disparities. |
| A new mother delays postpartum care because taking unpaid time off could cost her job. | Economic Stability & Employment | Workers in the lowest income quartile are 3x more likely to suffer workplace injuries and face increased chronic stress and hypertension. |
| A high school student drops out due to food insecurity at home, entering a cycle of poor education, low income, and poor health. | Education Access & Food Security | Adults in food-insecure households are 33% more likely to develop diabetes and 21% more likely to have heart disease. Individuals with parents who didn’t finish high school are 4x more likely to be in poor health. |
How Presidium Health Responds
At Presidium Health, addressing Social Determinants of Health is not supplemental care- it is the care. We embed SDOH support directly into care delivery. We believe that meaningful health improvement begins with understanding the full context of a person’s life. We understand that SDOH needs necessitate unique and innovative solutions. Learn more about the key differences between social determinants and other health factors and why that distinction matters in creating lasting solutions.
We operate with the conviction that trust is built through action. Our interdisciplinary care model is designed to proactively address the nonmedical barriers that stand in the way of good health. Our teams don’t wait for members to ask for help, we anticipate needs, build relationships, and intervene early. Whether a person is facing eviction, lacking a phone, or missing appointments due to caregiving responsibilities, we meet them with respect, solutions, and consistency.
We Provide Wraparound Social Care
Our services go far beyond referrals—we deliver structured, coordinated interventions that are personalized and integrated into every member’s care plan. These include:
Housing Stability
- Eviction/homelessness crisis response
- Housing authority coordination
- Low-income housing enrollment
- Household item provision
- Tenancy support
Transportation Access
- Non-emergency scheduling
- Gas cards & transit passes
- Rideshare for medical needs
- Wheelchair transport
- Medical oversight rides
Food & Nutrition
- CalFresh/SNAP & WIC help
- Tailored meal delivery
- Emergency food access
- Cultural food education
- Custom meal plans
Behavioral Health
- Mental health therapy
- Substance use integration
- Peer support workers
- Crisis response training
Health Navigation
- Medical visit coaching
- No-show reduction
- Telehealth advocacy
- Insurance support
Care Transitions
- 48-hour post-discharge follow-up
- Medication coordination
- Discharge planning support
- Red flag prevention
Documentation & Benefits
- Photo ID recovery
- SSI/SSDI & Medi-Cal apps
- Legal and tax support
- Digital literacy training
Employment Services
- Career coaching
- Resume & job search help
- Interview training
- Job retention support
Integrating Social Determinants of Health (SDOH) Into Care Delivery
We begin with a comprehensive social risk screening at intake and re-evaluate SDOH needs during key moments like hospital discharge, ED visits, or life transitions. Using evidence-based tools and real-time data, we prioritize urgent needs and deliver wraparound interventions through a team that includes:
- Social workers
- Community health workers
- Peer specialists
- Behavioral health clinicians
- Housing and benefits navigators
- Local community-based organizations and community partners
Presidium’s care framework is rooted in trauma-informed, culturally competent, and equity-driven practice. We align our workflows with national frameworks from Healthy People 2030, the Robert Wood Johnson Foundation, and California’s CalAIM Enhanced Care Management and Community Supports initiatives.
Beyond services, we partner with health plans, county agencies, and community groups to close systemic gaps—bridging medical care with the everyday realities that shape health. Our interventions don’t just reduce ER overuse and inpatient admissions; they build the conditions for long-term health resilience.
Presidium Health is where clinical care meets social accountability—because treating illness without addressing its root causes is no longer acceptable in modern healthcare.
Why This Matters- Now More Than Ever
As healthcare evolves toward value-based models, addressing SDOH is a performance and ethical imperative. National and state strategies—like Healthy People 2030 and California’s CalAIM—call for cross-sector investment in community health assessments, social protection, and structural reform. Learn how Social Determinants of Health uniquely impact California residents. The COVID-19 pandemic exposed the devastating consequences of ignoring social risk factors. And today, tobacco use, food insecurity, and unequal access to care continue to deepen disparities—especially among historically marginalized communities.
To reduce preventable costs, elevate quality, and build healthier futures, we must go beyond medical care. We must address the conditions that shape people’s health before they ever see a doctor. At Presidium Health, we’re not waiting for change. We’re building it.
Want To Learn More?
If you’re a provider, health plan, or policymaker seeking to better integrate Social Determinants of Health into care strategy, contact us today. Together, we can build systems that not only heal—but prevent.
