Addressing the social determinants of health (SDOH) is a critical step in reducing health disparities. Leading health agencies have organized SDOH into six groups: food security, economic stability, education, neighborhood and physical environment, community and social context and the healthcare system. Studies indicate that these social and economic forces account for nearly 70% of all health outcomes. While there has been considerable and quality research identifying SDOH and the mechanisms that explain their impact, the best approaches to integrating health services with community and social services are yet to be defined.

Community health centers are at the forefront of interacting with patients who face unmet social needs. In Durham, Lincoln Community Health Center (LCHC) is a trusted community institution, known for providing high quality care to low-income and uninsured people in the community. LCHC is also at the cutting edge of reimagining the role of primary care to be more responsive to upstream drivers of health by screening and responding to their patients’ social needs.