Connecting Patients With Community Resources to Improve Health: NQF Releases Recommendations for Using SDOH Data 

MAR 05, 2024

CONTACT: Zachary Brousseau

Connecting Patients With Community Resources to Improve Health: NQF Releases Recommendations for Using SDOH Data
Experts tested recommendations in real-world healthcare settings to identify strategies to help patients address health-related social needs

Washington, DC – The National Quality Forum (NQF) has released recommendations for healthcare organizations seeking to help patients address the nonmedical factors impacting their health. With recent payer and purchaser expectations that providers collect data about patients’ social drivers of health (SDOH), providers are seeking solutions to the important matter of how to effectively use these data to achieve better outcomes for patients. 

NQF’s Leadership Consortium, a group of senior healthcare experts and stakeholders, spent the past two years examining the issue, developing strategies, and then applying them in real-world healthcare settings to come up with a set of tested recommendations for navigating the complexities of leveraging SDOH data to improve health outcomes. The recommendations are summarized in a new report released today, Social Drivers of Health Data Utilization: Integrating Healthcare and Community Services to Address Health-Related Social Needs

SDOH, such as access to healthy food, safe housing, and transportation, have a significant impact on an individual’s health outcomes. Up to 90 percent of health outcomes may be attributable to socioeconomic and behavioral factors broadly referred to as SDOH, according to the National Academy of Medicine. Healthcare teams are well positioned to identify patients’ health-related social needs (HRSNs) but struggle to address these needs that may go beyond the scope of patient encounters in care settings. 

“SDOH data hold great potential to broaden our approach to patient health and amplify improvements in health outcomes for patients confronting these everyday challenges” said Leadership Consortium Co-Chair Peter Angood, MD, FRCS(C), FACS, MCCM, President and CEO of the American Association for Physician Leadership. “We also understood very well that overcoming obstacles to effective utilization of SDOH data is an ambitious and complex undertaking, and we chose to focus on partnerships between healthcare providers and community-based organizations. These recommendations offer field-tested promising practices that have practical application in real-world care settings, as well and helpful existing resources that anyone can access.” 

Members of the Leadership Consortium set out to find efficient and effective ways to leverage SDOH data to connect patients with helpful resources in their own communities and developed a set of initial recommendations. A subset of four member organizations then served as implementers to test the recommendations. The U.S. Department of Veterans Affairs (VA), the Case Management Society of America (CMSA), the Texas Health and Human Services Commission (Texas HHSC), and Phreesia evaluated the recommendations in diverse clinical settings across five projects. 

Implementers shared their findings with the full Consortium, which then worked together to identify key lessons learned, barriers, resources, and outcomes. More information about each of the individual projects and their results can be found in the report along with final recommendations. 

The report offers guidance on systematic ways to improve partnerships among patients, healthcare teams, community partners, and the broader healthcare community, leveraging digital platforms and streamlining multidirectional communications. The Consortium’s recommendations apply to a wide healthcare audience but is particularly salient for leaders who are navigating the complexities of managing SDOH data and addressing HRSNs to improve health outcomes. 

“Solving the technical challenges with sharing HSRN data across different IT systems with differing capabilities as well as standardizing this data are important steps in measurement, which will facilitate tracking of patient outcomes,” said Co-Chair Reena Duseja, MD, MS, Senior Advisor, Assistant Under Secretary for Health for Quality and Patient Safety for the Veterans Health Administration. “Just as important if not more so, is prioritizing a solution that is patient-centered. We must maintain patients’ trust with this data, strive to capture outcomes that are important to patients, and co-create interventions that make the most sense for patients’ well-being.” 

The report acknowledges the significant barriers to effective SDOH data collection and utilization, including financial and human resource availability, referral and communication workflow optimization, and data integration and interoperability. While these and other improvement opportunities remain to be addressed before the full potential of these data can be realized, the Consortium’s recommendations provide needed guidance and a meaningful starting point. 

The Leadership Consortium is an NQF Member-exclusive forum that includes a diverse range of perspectives designed to elevate NQF members’ voices to help drive measurable improvements by catalyzing action on some of healthcare’s more difficult and important challenges. A new Consortium is seated every two years with the first year dedicated to identifying a priority issue and developing recommendations, and the second year, to implementing and testing them, and sharing practical lessons learned. 


About National Quality Forum

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to improve healthcare outcomes, safety, equity, and affordability. Our unique role is to bring all voices to our table to forge multistakeholder consensus on quality measurement and improvement standards and practices that achieve measurable health improvements for all. NQF is a proud affiliate of The Joint Commission. Learn more at