Study Background
Addressing social determinants of health (SDOH)—the contextual drivers such as food insecurity, housing instability, and transportation challenges—is crucial for improving health outcomes, particularly among high-risk patients in community settings. Care management programs in community health centers (CHCs) are increasingly tasked with identifying and mitigating these social needs to reduce healthcare disparities and promote holistic care. Electronic health records (EHRs), enhanced with integrated care management modules, have the potential to support these efforts by facilitating systematic screening, referral-making, and follow-up coordination.
