Condition, diagnosis, or reason for seeking medical attention.

Data Element

SDOH Problems/Health Concerns

An identified Social Determinants of Health-related condition (e.g., Homelessness (finding), Lack of adequate food Z59.41, Transport too expensive (finding)). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

Applicable Vocabulary Standard(s)

Applicable Standards
  • ​​​​SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • International Classification of Diseases ICD-10-CM 2021


NACHC, PRAPARE and Gravity

Social Determinants of Health have been defined as:


They are a primary source of health inequities, lead to poorer health outcomes and interfere with a patient’s ability to participate in a health treatment plan. FQHCs have always been leaders in responding to SDOH concerns, as they serve populations with a high burden of unmet social and financial needs, and by definition provide enabling services, including case management, referrals, translation/interpretation, transportation, eligibility assistance, health education, environmental health risk reduction, health literacy, and outreach. These health-related and non-medical services address unmet needs that would interfere with successful participation in a medical treatment plan. Furthermore, health centers respond in a culturally-competent way, with diverse staff, community outreach and mental health and other emotional support tools.


NACHC is the co-creator and co-owner of PRAPARE, a national standardized patient risk assessment protocol built into the EHR designed to engage patients in assessing and addressing social determinants of health.

  • While FQHCs have been successful in asking their patients about and responding to SDOH needs, they have struggled to integrate these data into their EHRs and workflows in part because of lack of standardization around the data form and manner and the lack of regular use of structured terminology to describe these data (see Figure 2 below). Standardizing the PRAPARE domains and coding along with the Uniform Data Set (UDS) domains would significantly improve this gap.
  • Further work is needed to fill in similar gaps around essential services and social interventions and we encourage ONC to create a data class for Social Interventions which we would suggest would be used both for Referrals and for Encounters for social services. 

Addressing SDOH in clinical settings: 

  • To address SDOH in clinical settings we will need to promote content to facilitate improved patient-centered outcomes. To that extent, NACHC has initiated a working collaboration with EHR vendors and Community Health Center partners to improve the collection and operationalization of SDOH data. Our model, highlighted in Figure 3, includes an expansion of the team curating the problem list, coupled with a share care plan between various health care providers. To this extent, we support electronic care plan standards for documentation and interoperability. 


Please see attached document for a detailed summary of our comments on SDoH

2022-04-30 NACHC USCDIv3 Letter of Support_0.pdf

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