Assessing and Addressing Social Determinants of Health: A Key Competency for Succeeding in Value-Based Care

Prim Care. 2019 Dec;46(4):561-574. doi: 10.1016/j.pop.2019.07.013. Epub 2019 Jul 31.


There is growing recognition that social determinants of health influence individual and population health. A well-designed population health management strategy can yield improved outcomes for a given community, while improving the financial health of health care systems and providers. This article provides an overview of aligned care delivery, community engagement, education, technology, and other key strategies required to address the needs of patients and communities. A holistic vision incorporating social factors can lead to a return on investment and improvement in the health of a community, at the same time decreasing health care costs for the population managed.

Keywords: Innovation; Return on investment; Social determinants of health.

Publication types

  • Review

MeSH terms

  • Healthcare Disparities
  • Humans
  • Managed Care Programs / organization & administration
  • Medicaid / organization & administration*
  • Medicare / organization & administration
  • Population Health Management
  • Social Determinants of Health* / economics
  • State Health Plans / organization & administration
  • United States