Social determinants of health (SDOH) are widely known to have profound effects on overall health.¹ Variables such as wealth and income, educational attainment, dietary habits and food access, cultural influences, access to parks and sports, cleanliness of the local environment, number and quality of relationships, and the presence of meaningful spiritual expression all affect a community's health in significant ways.^2,3 Certain SDOH may even have a greater impact on health than commonly performed clinical services such as cancer screenings.⁴

Yet most clinics don't address SDOH in a meaningful way. Doing so requires a major shift in the way we think about disease diagnosis and treatment, and the way we allocate resources. This article describes an innovative practice model in which an outpatient clinic can creatively and effectively address SDOH in a primary care setting.