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Best Practices in Healthcare: Assessment of Social Determinants of Health (SDOH) Using the Department of Veterans Affairs (VA) Social Work Practice Model

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**Presented at the 2022 CMSA Annual Conference**
*** RN, CCM and SW credits ***
Primary care is critical for improving population health and reducing health disparities, particularly regarding prevention. Health disparities are a measure of differences in health outcomes between populations. Disparities in access to primary health care exist, and many people face barriers that decrease access to services and increase the risk of poor health outcomes. Social determinants of health (SDOH) are conditions in the environments where people are born, live, learn, work, worship and age that affect a wide range of health, functioning, and quality of life outcomes and risks. Healthy 2030, categorizes the Social Determinants of Health in five domains: •Economic Stability •Education and Quality •Health Care Access and Quality •Neighborhood and Built Environment •Social and Community Context Understanding the broader social, economic, and behavioral contexts impacting a person’s quality of life and well-being can help promote patient-centered care. Equitable access to high-quality care for all Veterans is a major tenet of the VA health care mission. The elimination of health disparities to achieve health equity for all Veterans. Advancing the health of our population requires us to recognize the needs of the populations we serve. Developing mechanisms for identifying and addressing population-level SDOH and individual-level health-related social needs in clinical settings can help us improve patients’ clinical outcomes and promote health equity. The VA Social Work Practice Model is a national standard for Patient Aligned Care Team (PACT) social workers to address social determinants of health with the Veteran population. PACT social workers are embedded within VA primary care teams. The model focuses on assessment in six key domains – access to care, economics, housing, psychological status, functional status, social supports and housing. The VA Social Work Practice Model and approach has shown increased positive outcomes including reductions in emergency department visits and unplanned hospital stays (Cornell, et al., 2020). It is critical to understand the impact of primary care social workers on health outcomes and their wellbeing (Anastas, 2014) and to place assessment tools into practice to capture SDOH deficits to ensure the highest quality outcomes for patient health and wellness.


  1. Define Social Determinants of Health (SDoH) and Health Disparities and Health Equity.
  2. Describe the importance of screening for Social Determinant of Health deficits.
  3. Describe the VA Social Work Practice Model and how implementation of the model improves health outcomes.