Social Determinants of Health in Primary Care

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Organization Type: 
Educational Institution
Program Type: 
Standing Program
Education Level: 
Postgraduate (e.g., residency, fellowship)
Continuing Education
Educational Elements: 
Self Reflection Activities
Other Element(s): 
Case studies from practice experience
Program Description: 

The Social Determinants of Health in Primary Care program provides practical education to physicians, nurses, medical assistants, front desk staff, and other practice staff through four sessions: 1) The impact of psychosocial issues on physical health; 2) Encouraging and teaching self-management; 3) mental health; and 4) cultural competency. 

Individuals often balance chronic conditions and physical concerns with psychosocial issues, such as access to social services and entitlements. As a result, chronic conditions can seem less urgent than meeting daily needs. The balance is even more difficult in underserved communities where psychosocial issues may be more common and fewer resources are available. Many issues can be addressed using community resources if patients and caregivers with service needs are identified in primary care, such as in a patient-centered medical home (PCMH), and health professionals, specifically social workers, educate them about accessing available services. This training enhances the awareness of practice staff on the role of non-medical factors in health and enhances the skills and knowledge around addressing these issues.

The program is structured with four 60-minute didactic lunch-and-learns, with topics as follows:

  1. Social Determinants of Health:  Overview of definition of social determinants of health; examination of the role of social support in patient health; opportunities for PCMH to support patients and caregivers; discussion of case studies from within practice.
  2. Chronic Disease Self-Management: Overview of impact of chronic conditions on patient and caregiver well-being; impact of chronic conditions on health care system; examination of issues affecting self-management; discussion of how to support self-management in the practice; discussion of case studies from within practice.
  3. Mental Health Needs of Primary Care Patients: Overview of mental health in general; examination of primary care as a critical portal to mental health treatment; introduction to severe/persistent mental illness; introduction to depression (including in later life), treatment modalities; discussion of value of universal screening; discussion of case studies from within practice.
  4. Cultural Competency: Overview of what is meant by cultural competency; discussion of role of own culture in delivering care; examination of implications of cultural competency and ways to increase it in practice; discussion of case studies from within practice.

The program has been evaluated using a pre-post test analysis.

Program Results: 

Based on a pre-post test analysis, providers knowledge and skills increased significantly; specifically providers showed improvements in confidence (self-rating of “mostly confident” or “completely confident” on five-point Likert scale) for the following knowledge areas:

  1. What to do when non-medical barriers are encountered in a patient (increase from 23.1% to 88.2%)
  2. How addressing social determinants relates to PCMH principles (38.5% to 88.2%)
  3. Unique challenges faced by diverse populations in adhering to their care plan (46.2% to 75.9%)
  4. How social determinants affect patients individually as seen in the practice (53.9% to 94.1%)
  5. Psychological factors impacting patient’s ability to adhere to the plan of care (53.9% to 88.2%)
  6. Factors deterring people from seeking medical treatment (46.2% to 88.2%)

Improvements were also seen in the following skills:

  1. Ensure mental health needs are addressed (increased from 25.0% to 70.5%)
  2. Identify opportunities for case management within medical visit (33.3% to 82.3%)
  3. Empower patients to effectively manage their health (33.4% to 82.3%)
  4. Support adherence to treatment in the presence of non-medical barriers (33.3% to 82.3%)
  5. Address psychosocial needs of patients (41.7% to 76.5%)
Targeted Professions
Family Medicine
Internal Medicine
Nurse Practitioners
Registered Nurses
Licensed Practical Nurses
Ambulatory Care
Internal Medicine
Social Work: 
Medical social work
Clinical Health
Medical Assistants
Patient Educators
Physician Assistants
Geriatrics; Front desk staff
Self-Reported Competencies
PCPCC’s Education and Training Task Force identified 16 interprofessional training competencies critical for preparing health professionals for practicing in team-based, coordinated care models such as patient-centered medical homes. Listed below are the self-reported competencies that this program has achieved, which have been organized by the five core features of a medical home as defined by the Agency for Healthcare Research and Quality
Patient-Centered Care Competencies: 
Advocacy for patient-centered integrated care
Cultural sensitivity and competence in culturally appropriate practice
Development of effective, caring relationships with patients
Patient-centered care planning, including collaborative decision-making and patient self-management
Comprehensive Care Competencies: 
Assessment of biopsychosocial needs across the lifespan
Risk identification
Coordinated Care Competencies: 
Care coordination for comprehensive care of patient & family in the community
Quality Care & Safety Competencies: 
Quality improvement methods, including assessment of patient-experience for use in practice-based improvement efforts
Last updated November 15, 2013

* Please note: Information contained in this database is self-reported by representatives from each program. It does not represent an exhaustive list of education and training programs and inclusion does not constitute an endorsement from the PCPCC.


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