Social Determinants
The data has been unambiguous for years.
Patients experiencing housing instability are readmitted at dramatically higher rates. They miss follow-up appointments. They can't adhere to medication regimens that require refrigeration, consistent schedules, or a stable address. They show up in emergency departments for conditions that should have been managed in primary care — because the ED is the only place that can't turn them away.
We know this. The research is not new. The connection between housing and health outcomes has been documented across dozens of studies, in multiple populations, across every major chronic disease category.
And yet most health systems still treat housing as someone else's problem.
The statistic that gets cited most often in social determinants of health conversations is this: approximately 80 percent of health outcomes are determined by factors outside the clinical encounter.
Housing. Food security. Transportation. Social connection. Economic stability. Education. These are the upstream drivers of the conditions that fill hospital beds and drive the cost curves that keep health system CFOs awake at night.
The clinical encounter — the doctor's visit, the procedure, the prescription — accounts for roughly 20 percent of what determines whether a patient is healthy.
We have built an entire industry around that 20 percent. We have optimized it, measured it, regulated it, and reimbursed it with extraordinary sophistication. The 80 percent, we have largely left to social service agencies operating on grant funding with no integration into the clinical workflow.
This is not a values failure. It's a structural one. The incentives have never pointed toward the upstream.
When a patient is discharged from a hospital and readmitted within 30 days, the clinical instinct is to look for a clinical explanation. Was the discharge premature? Was the care plan inadequate? Was there a medication error?
Sometimes the answer is yes. But a significant portion of readmissions — particularly in Medicaid populations — trace back to something that has nothing to do with the quality of the clinical care. The patient went home to an environment that made recovery impossible.
No heat in winter. Mold that exacerbates respiratory conditions. A living situation so unstable that medication adherence is simply not a realistic priority.
The 30-day readmission penalty, introduced under the Affordable Care Act, was designed to incentivize hospitals to improve care transitions. What it actually did, in many cases, was penalize hospitals for the social conditions of their patient populations — conditions the hospital had no mechanism to address.
The policy was right about the problem. It was wrong about where the leverage was.
I've had this conversation with health system executives many times. The logic is always some version of the same thing: we are a healthcare organization, not a housing organization. We don't have the expertise, the infrastructure, or the mandate to solve housing. That's what community organizations are for.
There's a version of that argument that's reasonable. Health systems shouldn't become landlords. They shouldn't try to replicate the work of housing authorities or community development organizations.
But there's a difference between becoming a housing organization and treating housing as a clinical input.
When a cardiologist prescribes a medication, they don't manufacture the drug. They prescribe it, and a pharmacy fills it. The cardiologist's job is to identify the clinical need and connect the patient to the appropriate resource.
The same logic applies to housing. The health system's job is not to build affordable housing. It's to screen for housing instability, document it in the medical record, connect patients to housing resources, and track whether those connections are made and whether they produce the expected clinical outcomes.
That's not a housing organization. That's a healthcare organization that takes the 80 percent seriously.
The organizations that have made meaningful progress on SDOH integration share a few characteristics.
They screen systematically. Not just when a patient looks like they might have social needs — every patient, every encounter, with a validated instrument that produces structured data.
They have closed-loop referral systems. Not a list of community resources that gets handed to the patient at discharge. An actual workflow that sends a referral, confirms receipt, tracks completion, and feeds the outcome back into the medical record.
They measure it. They track housing instability rates in their patient population. They track referral completion rates. They track whether patients who received housing interventions had lower readmission rates than those who didn't. They treat SDOH outcomes the same way they treat clinical outcomes — as data that drives decisions.
And they have someone accountable for it. Not a committee. Not a task force. A person whose job it is to make this work.
None of that is easy. All of it is possible. The organizations doing it are not doing it because they're more virtuous than their peers. They're doing it because they've done the math and concluded that the upstream investment is cheaper than the downstream cost.
The objection I hear most often is: we can't get paid for it.
This is less true than it used to be. CMS has expanded reimbursement for social determinants screening and intervention. Several states have added SDOH-related codes to their Medicaid managed care contracts. Value-based arrangements increasingly include quality metrics that are only movable if you address the upstream.
But the reimbursement question, while real, is also a bit of a red herring. The organizations that have made the most progress on SDOH integration didn't wait for the reimbursement to catch up. They made the investment because the total cost of care math was compelling — and because they understood that in a value-based world, the organizations that figure this out first will have a structural advantage over those that wait.
Housing is a clinical intervention. The evidence is there. The tools are available. The only thing missing is the will to treat it that way.
"We have built an entire industry around 20 percent of what determines health. The 80 percent, we have largely left to social service agencies operating on grant funding."
About the author
Alex Yarijanian is a healthcare strategist, founder, and speaker. He writes about leadership, systems, and the gap between how organizations say they work and how they actually do.