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Social Determinants of Health (SDOH)

Social Determinants of Health (SDOH)

The Healthy People 2030 initiative by the U.S. Department of Health and Human Services (HHS), designed to guide national health promotion and disease prevention efforts to improve the health of the nation, defines an overarching goal specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”


Why SDOH Matters

Data is the key for building a robust and efficient SDOH strategy, which is needed to address health and healthcare disparities and achieve health equity. The CMS Framework for Health Equity 2022–2032 also identified Priority 1 as expanding the collection, reporting, and analysis of standardized data. The HIE strives to improve our collection and use of comprehensive, interoperable, standardized individual-level demographic and SDOH data. As stated in CMS Framework for Health Equity 2022–2032, increasing our understanding of the needs of those we serve, including social risk factors and changes in communities’ needs over time, gives us instruments to leverage quality improvement and ensure all individuals have access to equitable care and coverage.



The VHIE has several initiatives related to SDOH planning and ingestion.  Examples include:

  1. Ingestion of New to Medicaid (NTM) and General Assessment (GA) surveys into the VHIE, using the questionnaire resource within Fast Healthcare Interoperability Resource (FHIR).
  2. Establishing a consulting contract to build an SDOH Roadmap for the Agency to chart a path forward on SDOH.
  3. Collaborating with other State and private entities to establish collective vision for using the CMS Health-Related Social Needs (HRSN) screening tool