SGIM Forum

Sign of the Times: Part I

The Wake of the Outbreak: COVID-19 and Social Determinants of Health

Mr. Wilhite ( is a researcher at NYU School of Medicine’s Program for Medical Education Innovations and Research (PrMEIR). He manages the Unannounced Standardized Patient program. Ms. Fisher ( facilitates program implementation and coordination for PrMEIR. Dr. Zabar ( is the director of the Division of General Internal Medicine and Clinical Innovation at NYU Grossman School of Medicine, director of PrMEIR, and a professor within the Department of Medicine.

News of the first confirmed case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly referred to as COVID-19, in New York City (NYC) broke on March 1, 2020. By the end of March, the worldwide case rate had ballooned to nearly 800,000, with a directly-attributable-to-disease death rate above 40,000.1 This number has grown exponentially since the early days of the outbreak. In mapping the spread, researchers identified an alarming trend: the most acutely impacted communities are located within low-income, minority areas.2 Similar trends have since emerged across the United States, from large urban centers to smaller communities and towns. More concretely, emerging evidence suggests that Black and Hispanic individuals are as much as 3.5 and 2 times more likely to contract and face complications from COVID-19 than White individuals, respectively.2 In this article, we describe how key SDoH have been exacerbated by the COVID-19 pandemic and how certain populations will face long-term implications hereafter. We use this information to make recommendations for health systems on how best to prepare care teams for the wake of COVID-19.

The COVID-19 pandemic has shed new light on the critical importance of the social determinants of health (SDoH), or the conditions in which people live, work, and grow. SDoH encompass a range of issues including income level, housing and insurance status, and distance from medical care, among others. A wealth of evidence says that SDoH directly impact a person’s health status and mortality risk, and COVID-19’s emergence has further affirmed the relationship between SDOH and health outcomes. As Americans shifted toward isolation when possible, lower-income and service industry workers whose work is considered essential have continuously faced exposure to the illness.3 Additionally, lower-income workers, especially those living in households comprised of people of racial minorities and lower educational attainment, are also experiencing increasing rates of furlough and unemployment as the pandemic progresses.1 Data trends show that those most directly impacted by job loss include minorities, women, and those with less than a college education.4 Transition to telework has been reserved for those with a college degree, with 66% successfully switching compared to only 22% of those without a degree.4 Lower-income minorities are also likely to be impacted by societal consequences of COVID-19, such as reduced healthcare access due to layoffs or lack of insurance status, and housing insecurity, long after the initial outbreak.1

The longer-term implications of the pandemic will more clearly unfold as the healthcare industry attempts to begin to return to normalcy in the next several months.3 As communities begin returning to the “new” normal in the wake of COVID-19’s declining numbers, we will likely see an increase in routine medical care and office visits for the general population, but those with existing and newly emerging SDoH will need multi-level care that addresses both present illness and underlying SDoH-related issues.

Addressing SDoH in the Wake of the Outbreak

Financial struggles and insurance issues are linked to decreased access of health services for treatment for long-term follow-up so systems must be prepared to address the immediate needs of patients as they return to seeking clinical care, especially in safety-net hospital systems.1 Increasing awareness around processes and channels to mitigate the long-term repercussions of the relationship between COVID-19 and SDoH will be essential in protecting livelihoods in affected communities. How can we, or the larger health systems that care for this population, prepare to provide the high-quality services needed?

Step 1: Assess System Capacity to Engage with Patients Presenting with SDoH-Related Issues

Systems should begin with a needs assessment of their capacity to engage with patients presenting with underlying financial and housing insecurity, unemployment, and food access issues. A necessary first step is examining the care team’s ability to link patients with community programs available through the hospital system. For example, when a patient presents without insurance or can’t afford a copay, do clinical staff know best practices in referring them for low-cost or free services, whether that is testing for COVID-19 or routine medical testing? Or when a patient visits with concerns over affording rent due to job loss, do care teams know the referral and community resource networks available for homelessness prevention? Which free or low-cost counseling services exist for patients who have developed anxiety or trauma during the onset of the pandemic? Which practices (through EHR documentation/ charting perhaps) are necessary to ensure long-term follow-up for these patients?

Understanding this capacity begins with taking an environmental scan of staff and care team member communication surrounding SDoH, and what knowledge exists on referral channels/resources available. This initial scan could be accomplished through simple methods like team efficacy surveys or interviews. Questions targeting provider efficacy and comfort in communicating with unique patient concerns is a critical first step in unpacking this capacity. Second, understanding precisely how providers communicate surrounding SDoH is a critical piece of the puzzle. Exploring what happens in the room between a patient and their provider can be accomplished through tools like unannounced standardized patients (USPs), or secret shoppers. These secret shoppers visit a clinic and collect data on health systems practices from intake to discharge. An examination of how providers elicit, acknowledge, and respond to patient SDoH is essential and tools like these provide the system with valuable knowledge and feedback on gaps in knowledge and areas for necessary improvement.5

Step 2: Design Training Programs to Address Gaps in Capacity

Following a scan of the clinical environment, training that targets all levels of the care team, including front desk, clerical, physician assistant, nurses, and physicians, on identifying, referring, and documenting these patients SDoH should be introduced. Long-term care for those with financial instability/ housing insecurity extends beyond initial identification and referral. We’ve been able to move the needle in our own hospital system on rate of provider willingness to engage with and provide resources to patients with underlying SDoH by as much as 21% through routine feedback and education.5 Even with feedback, though, providers oftentimes struggle to know referral options available and fail to document these issues for follow-up. Training must focus on emphasizing both documentation for follow-up and utilization of established referral networks to ensure access to community services. Further, training that not only builds capacity and understanding, but increases willingness to engage with unique patient populations is essential. Preparing our clinical systems to handle these patients in the future begins with assessing and educating and concludes with patients accessing a social service as part of their long-term, integrated care plan.

The rapid spread of COVID-19 has implications for everyone, but those who are impacted most directly by financial, housing, employment and food insecurity will face longest ramifications in terms of healthcare access, follow-up, and decreased livelihood. These communities, while already impacted by a burden of being much more susceptible to rapid community spread now face long-term issues with finances and care access. Ensuring that teams are able to effectively communicate with patients about SDoH and refer them to appropriate resources will prepare hospitals for the aftermath of the pandemic. Increasing the entire healthcare team’s capacity to address SDoH will be essential for the recovery and future health of our communities.


  1. Béland LP, Brodeur A, Wright T. The short-term economic consequences of Covid-19: exposure to disease, remote work and government response. SSRN. Posted April 27, 2020. Accessed October 15, 2020. (As of this printing, this paper is not yet peer reviewed.)

  2. Gross CP, Essien UR, Pasha S, et al. Racial and ethnic disparities in population level Covid-19 mortality. medRxiv. Published online May 7, 2020. doi:10.1101/2020.05.07.20094250.

  3. Almagro M, Orane-Hutchinson A. The determinants of the differential exposure to COVID-19 in New York City and their evolution over time. SSRN. Last revised June 22, 2020. Accessed October 15, 2020.

  4. Kochhar R. Hispanic women, immigrants, young adults, those with less education hit hardest by COVID-19 job losses. Published 2020. Accessed September 23, 2020.

  5. Wilhite J, Zabar S, Hanley K, et al. Do providers document social determinants? Our EMRs say…! Presented at Society of General Internal Medicine Annual Meeting (SGIM-on-Demand), June 2020. (You must have an account to view this material.)


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