From the Causes of the Causes to a Clinic Workflow: Defining the Social Determinants of Health and Screening for Them in a Federally Qualified Health Center
[Student Name]
University of Phoenix
NSG/507: Social Justice and Information Systems for Population Health
Week 2 Assignment
[Instructor Name]
[Date]
The health center, patients and figures are a composite written for a model paper.
A composite 58-year-old home health aide with type 2 diabetes returned to a federally qualified health center with a hemoglobin A1c of 10.4%, higher than at her last visit. Her nurse practitioner had already adjusted her medications twice. On a new screening questionnaire completed in the waiting room, she checked two boxes: in the past year she had run out of food before she had money to buy more, and she had missed appointments because she lacked transportation. Her medication list had been treated as the problem for a year, while the reasons her diabetes was worsening sat in answers no one had asked for. This paper defines the social determinants of health, distinguishes them from the social needs a clinic can identify and describes how one health center began screening for those needs and using the results.
Defining the Social Determinants of Health
Healthy People 2030 describes the social determinants as the conditions of the places where people are born, live, learn, work, play, worship and age that shape a wide range of health risks and outcomes, and sorts them into five domains: the economy and a household's stability within it, education, health care access, the physical neighborhood people live in, and their social and community ties (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). The domains are useful for a clinic because each one suggests questions that can be asked of an individual patient.
Marmot (2005) argued that the social determinants explain most of the inequalities in health within and between countries, and that these inequalities follow a social gradient: health worsens step by step as social position declines, not only at the bottom. Braveman and Gottlieb (2014) summarized the evidence linking income, education, working conditions, neighborhoods and social relationships to health, and urged attention to "the causes of the causes," the social and economic conditions that shape the behaviors and exposures medicine usually treats.
Two distinctions follow from these sources. First, determinants are not the same as behaviors: smoking or diet are influenced by the determinants, not determinants themselves. Second, determinants operate at the level of populations and policies, while social needs are how those determinants show up in the life of one patient, such as the woman who ran out of food before the end of the month.
From Determinants to Screening
A health center cannot change a county's wage levels or housing market from an exam room, but it can find out which patients are affected and connect them to help. The composite health center, which serves about 14,000 patients, most with incomes below twice the federal poverty level, adopted a standardized social needs screening tool derived from PRAPARE, the protocol developed by the national community health center association for assessing patients' social risks (National Association of Community Health Centers, 2016). The tool asks about housing, food, transportation, utilities, safety, social isolation and stress.
The workflow was designed with staff. Patients complete the screen on a tablet in the waiting room, in English or Spanish, once a year and whenever a clinician has a concern. Positive answers appear in the record for the medical assistant and clinician, and each positive screen triggers an offer of help from a community health worker, who can connect the patient to food assistance, transportation vouchers, utility assistance programs or legal aid.
What the First Six Months Showed
In six months, 5,120 patients were screened. About 38% had at least one positive answer; the most common needs were food insecurity at 22%, transportation at 14% and housing instability at 11%. Among patients with diabetes and an A1c above 9%, the share with at least one need was higher, at 52%, which supported the clinical team's suspicion that social needs were contributing to poor control.
Screening only helps if it leads somewhere. Gottlieb et al. (2016), in a randomized trial in a pediatric urgent care setting, found that social needs screening followed by in-person navigation by trained staff reduced families' reported social needs and improved caregiver-reported child health compared with screening and written information alone. The composite health center's experience matched this: patients who accepted the community health worker's help were far more likely to report that a need had been resolved at the next visit than those who received only a resource list.
Coding and Using the Data
The health center also began documenting positive screens with ICD-10-CM Z codes for social factors, such as codes for food insecurity and inadequate housing. Coding allowed the center to count needs across its whole population, to include them in risk adjustment reports and to study whether patients with particular needs had worse outcomes. The nurse practitioner who led the program reviewed the data quarterly and shared a one-page summary with clinicians, which reinforced why the screening mattered.
For the patient described at the start, screening changed care. The community health worker enrolled her in the Supplemental Nutrition Assistance Program, connected her with a food pharmacy program at the health center that provides produce for patients with diabetes and arranged Medicaid transportation for appointments. Her nurse practitioner simplified her insulin regimen to fit an irregular food supply. Three months later, her A1c had fallen to 8.9%.
From Needs Back to Determinants
Screening addresses needs one patient at a time. The aggregated data, however, point back to the determinants. The health center's report showed that food insecurity clustered in two neighborhoods served by a single bus route with no grocery store, and that housing instability had risen after rents increased sharply in one zip code. The nurse practitioner presented these findings to the county's health improvement coalition, where they supported proposals for a grocery delivery partnership and a local rental assistance program. This is how clinical screening can contribute to upstream change: by giving policy makers local data on the conditions their decisions shape.
Limits and Cautions
Screening raises ethical and practical questions. Asking about needs a clinic cannot address can frustrate patients, so screening should be paired with resources. Some patients may fear that disclosing needs, such as housing problems, could have consequences, which makes privacy and a clear explanation of why questions are asked essential. And screening can shift attention from policy to individual problems if the data are never used to advocate for structural change.
Conclusion
The social determinants of health are the conditions in which people live and work, distributed by social and economic forces, and they explain much of the inequality in health that clinicians see. Clinics encounter them as individual social needs. A health center that screens systematically, pairs screening with navigation, codes the results and shares the aggregated data with community partners can improve care for patients like the woman whose diabetes worsened for reasons no one had asked about, and can help move the conversation upstream to the causes of the causes.
References
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206
Gottlieb, L. M., Hessler, D., Long, D., Laves, E., Burns, A. R., Amaya, A., Sweeney, P., Schudel, C., & Adler, N. E. (2016). Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatrics, 170(11), Article e162521. https://doi.org/10.1001/jamapediatrics.2016.2521
Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099-1104. https://doi.org/10.1016/S0140-6736(05)71146-6
National Association of Community Health Centers. (2016). PRAPARE: Protocol for responding to and assessing patients' assets, risks, and experiences. https://prapare.org
Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
How this NSG 507 Week 2 example is structured
The University of Phoenix library guide for NSG/507 lists Week 2 as Defining the Social Determinants of Health. The paper spends real space on definitions, because the week asks for them and because confusing determinants with needs leads to poor programs. It then moves to practice, a screening workflow with data, and closes by connecting individual screening results back to the upstream determinants, which completes the argument that the definition should shape the program. Students search this week as NSG 507 Week 2, NSG507 Wk 2 or NSG/507 Wk 2; all three are the same assignment.
NSG/507 Week 2 questions, answered
What does NSG/507 Week 2 usually ask for?
The University of Phoenix library guide for NSG/507 lists Week 2 as defining the social determinants of health. Many sections ask for a paper that defines the determinants, explains how they affect a population's health and describes how advanced practice nurses assess or address them. Your instructions decide whether a specific population is required.
What is the difference between social determinants and social needs?
Social determinants are the conditions in which people are born, grow, live, work and age, shaped by the distribution of money, power and resources. Social needs are the individual, immediate problems those conditions create for a patient, such as food insecurity or unstable housing. Clinics mostly screen for needs; policy addresses determinants.
Should screening data be coded in the record?
Yes, where possible. ICD-10-CM Z codes for social factors let health systems count needs across a population and link them to outcomes, although coding remains uncommon in many settings.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.