Chronic diseases—such as diabetes, hypertension, heart disease, and respiratory conditions—are among the leading causes of death and disability globally. While medical treatment is essential, there is growing recognition that social determinants of health (SDOH) play a critical role in shaping the outcomes of chronic disease management.
Neftaly emphasizes the importance of understanding and addressing SDOH as part of a holistic, patient-centered approach to chronic disease care. By doing so, healthcare providers and systems can more effectively reduce health disparities and improve long-term outcomes.
1. What Are Social Determinants of Health (SDOH)?
Social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, live, work, and age, and include:
- Economic stability
- Education access and quality
- Healthcare access and quality
- Neighborhood and built environment
- Social and community context
These determinants influence everything from access to care and medication adherence to lifestyle behaviors and stress levels.
2. Link Between SDOH and Chronic Disease
SDOH can directly impact the prevalence, progression, and outcomes of chronic diseases in several ways:
| SDOH Factor | Impact on Chronic Disease |
|---|---|
| Economic instability | Inability to afford medications, healthy food, or transportation to clinics |
| Low education | Reduced health literacy and self-management capacity |
| Limited healthcare access | Delayed diagnoses, poor follow-up, low continuity of care |
| Unsafe neighborhoods | Limited physical activity, high exposure to environmental risks |
| Social isolation | Poor mental health, lack of support for disease management |
3. Common Barriers Driven by SDOH
- Medication non-adherence due to cost or lack of understanding
- Missed appointments because of lack of transportation or childcare
- Uncontrolled conditions due to poor diet in food-insecure households
- Higher stress and anxiety from housing instability or job insecurity
- Mistrust in healthcare from historical and cultural experiences
4. Neftaly Strategies to Address SDOH in Chronic Disease Care
a. SDOH Screening and Assessment
- Use standardized tools to assess patients’ social needs (e.g., PRAPARE, AHC HRSN)
- Integrate SDOH screening into routine care and EHR documentation
b. Patient-Centered Care Planning
- Develop care plans that consider patients’ financial, social, and environmental contexts
- Involve patients and caregivers in shared decision-making
c. Community Resource Referrals
- Build partnerships with local organizations for:
- Food assistance programs
- Housing support
- Transportation services
- Mental health counseling
- Legal aid and job placement
d. Care Coordination
- Employ community health workers, social workers, or case managers to bridge gaps
- Ensure follow-up on referrals and services accessed
e. Health Education and Literacy
- Tailor education materials to patient’s language and literacy levels
- Use visuals, simple language, and culturally appropriate messaging
5. The Role of Healthcare Providers and Teams
Neftaly recommends a multidisciplinary approach where all team members contribute to addressing SDOH:
- Clinicians identify clinical and social risk factors
- Nurses reinforce education and support care plan adherence
- Pharmacists assist with medication access and management
- Social workers and CHWs connect patients to resources and provide advocacy
- Administrators integrate SDOH into policy, billing, and strategic planning
6. Technology in Managing SDOH and Chronic Disease
- Telehealth for reaching patients in rural or underserved areas
- Mobile health apps to support self-management in low-literacy populations
- EHR systems with integrated SDOH data fields and referral tracking
- Predictive analytics to identify at-risk patients based on social risk data
7. Measuring Impact and Outcomes
Key metrics to evaluate the integration of SDOH in chronic disease care:
- Reduction in hospital readmissions and ER visits
- Improvement in disease-specific outcomes (e.g., HbA1c, BP control)
- Patient satisfaction and engagement scores
- Number of successful community resource referrals
- Improvement in quality-of-life measures
Conclusion
Neftaly recognizes that managing chronic disease requires more than just medical treatment—it requires addressing the social and structural factors that impact a patient’s ability to live a healthy life. By embedding SDOH awareness into clinical workflows, care coordination, and policy development, healthcare systems can deliver more equitable, effective, and compassionate care.
Addressing social determinants is not only a matter of better health—it is a matter of health justice.


