Episode Summary: In this transformative episode of Secrets of Survival, Dr. Susan Rashid unpacks the intersection of clinical care and the Social Determinants of Health (SDOH) through the lens of the CMS Accountable Health Communities Health-Related Social Needs (HRSN) Screening Tool. Amid the pressures of time-limited visits and documentation burdens, this episode argues for a paradigm shift—one where asking the right questions becomes a form of clinical justice. Segment by segment, Dr. Rashid walks listeners through the five core domains—housing instability, food insecurity, transportation barriers, utility needs, and interpersonal safety—and introduces supplemental domains including financial strain, employment, community support, education, physical activity, substance use, mental health, and disability. With clarity and compassion, she demonstrates how these structured questions serve as clinical windows into hidden vulnerabilities—revealing the context behind medication non-adherence, chronic illness exacerbation, and missed appointments. The episode emphasizes that screening is not merely data collection—it is clinical witnessing. The ability to ask, listen, and respond with actionable referrals is presented not as a luxury, but as a clinical imperative. Citing national guidelines and landmark evidence from CMS, the National Academies, and leading scholars, Dr. Rashid reframes SDOH as the modern foundation of primary care. From medical education to healthcare system design, listeners are called to envision a future where healing is not confined to prescriptions, but extended through structurally aware care, community partnerships, and institutional accountability. This episode is both a masterclass in clinical application and a compelling call to action for medical educators, health system leaders, and frontline clinicians. 📩 Thoughts or reflections? We welcome your insights, questions, and feedback. Email us: rashidmediaproductions@gmail.com 🎧 Subscribe to Secrets of Survival (S.O.S.) for future episodes exploring the intersections of medicine, society, and the diverse forces that shape our health.
Episode Summary:
In this transformative episode of Secrets of Survival, Dr. Susan Rashid unpacks the intersection of clinical care and the Social Determinants of Health (SDOH) through the lens of the CMS Accountable Health Communities Health-Related Social Needs (HRSN) Screening Tool. Amid the pressures of time-limited visits and documentation burdens, this episode argues for a paradigm shift—one where asking the right questions becomes a form of clinical justice.
Segment by segment, Dr. Rashid walks listeners through the five core domains—housing instability, food insecurity, transportation barriers, utility needs, and interpersonal safety—and introduces supplemental domains including financial strain, employment, community support, education, physical activity, substance use, mental health, and disability. With clarity and compassion, she demonstrates how these structured questions serve as clinical windows into hidden vulnerabilities—revealing the context behind medication non-adherence, chronic illness exacerbation, and missed appointments.
The episode emphasizes that screening is not merely data collection—it is clinical witnessing. The ability to ask, listen, and respond with actionable referrals is presented not as a luxury, but as a clinical imperative. Citing national guidelines and landmark evidence from CMS, the National Academies, and leading scholars, Dr. Rashid reframes SDOH as the modern foundation of primary care.
From medical education to healthcare system design, listeners are called to envision a future where healing is not confined to prescriptions, but extended through structurally aware care, community partnerships, and institutional accountability. This episode is both a masterclass in clinical application and a compelling call to action for medical educators, health system leaders, and frontline clinicians.
📩 Thoughts or reflections?
We welcome your insights, questions, and feedback.
Email us: rashidmediaproductions@gmail.com
🎧 Subscribe to Secrets of Survival (S.O.S.) for future episodes exploring the intersections of medicine, society, and the diverse forces that shape our health.
🎙️ Podcast Title: Secrets of Survival (S.O.S.)
🎧 Episode Title: “The Blueprint of Wellbeing: Public Health and the Social Determinants of Health - Part 2”
🩺 Written and Narrated by Dr. Susan Rashid
🎓 Tone: Scholarly | Informed | Direct | Authoritative
Narrator: Welcome to Secrets of Survival (SOS), a podcast exploring the systems, structures, and social conditions that shape health outcomes across the United States.
In today’s episode—“The Blueprint of Wellbeing: Public Health and the Social Determinants of Health”—we examine the upstream factors that influence health long before clinical care begins. From housing and education to transportation and safety, we explore the evidence behind how environments shape disease and longevity.
Guiding today’s episode is Dr. Susan Rashid—a physician, public health scholar, and founder of Rashid Media Productions. Dr. Rashid brings a clinically grounded, policy-informed perspective to the evolving intersection of medicine, equity, and public health.
Now, let’s begin.
Narrated by Dr. Susan Rashid
Dr. Susan Rashid: As we move from data to delivery, the next question becomes:
What is the clinician’s role in all of this?
In the clinical setting—where time is constrained, documentation demands are high, and the visit agenda is tightly structured—where exactly do the Social Determinants of Health fit in?
The answer is increasingly clear: they must become part of routine care.
While clinical medicine remains central to diagnosis and treatment, it is no longer sufficient to focus solely on disease without also recognizing the context in which disease arises. According to the U.S. Department of Health and Human Services, patients’ health-related social needs—such as unstable housing, food insecurity, utility shutoffs, and transportation barriers—have measurable effects on treatment adherence, recovery timelines, and avoidable emergency visits (Centers for Medicare & Medicaid Services, 2024).
In response to this need, the Centers for Medicare & Medicaid Services (CMS) developed a standardized, validated 10-item screening tool that is now considered a leading resource in clinical settings: the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool.
This tool is designed to identify unmet needs within five core domains of social determinants of health. Each question is intended to be answered directly by the individual patient or, when applicable, by a parent or caregiver on the individual’s behalf. The screening tool emphasizes brevity, accessibility, consistency, and inclusivity, making it suitable for integration into routine clinical workflows. While the complete AHC screening tool also includes eligibility criteria, demographic questions, and optional supplemental domains, the primary focus remains on the development and implementation of the core 10 questions targeting high-priority social needs.
Originally designed for use in the AHC Model, this tool identifies key social needs in five core domains:
Let us consider how this looks in practice.
During a routine primary care visit, a patient is asked the following question—drawn directly from the CMS AHC Health-Related Social Needs Screening Tool:
1. What is your housing situation today?
□ I do not have housing (I am staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
□ I have housing today, but I am worried about losing housing in the future.
□ I have housing
The second question for Housing Instability asks:
“Think about the place you live. Do you have problems with any of the following?”
(Check all that apply)
Environmental risks such as lead exposure, mold, and inadequate heating are directly associated with adverse health outcomes. Lead is linked to neurodevelopmental delays, particularly in children. Mold exposure worsens respiratory illnesses like asthma. Insufficient heating increases the risk of hypothermia and respiratory infections, especially among older adults and individuals with chronic disease.
Responses to these screening questions reveal critical dimensions of a patient’s lived environment—factors that are often invisible in standard clinical assessments. They provide context that may explain treatment non-adherence, repeated hospitalizations, or persistent symptoms, and remind us that effective care must extend beyond the exam room.
Housing Instability
Housing-related social needs encompass a range of challenges, including homelessness, unsafe or substandard housing conditions, and difficulty affording rent or mortgage payments. The first item aims to identify individuals experiencing homelessness or who are at imminent risk of housing loss. To align with the federal definition of homelessness, examples such as “abandoned building,” “bus station,” and “train station” were included.
Answer choices that reflect either current homelessness or risk of eviction due to inability to pay for housing are flagged as indicators of housing need within the AHC Model framework.
The second item targets substandard housing conditions. Respondents who report issues such as mold, inadequate heating, pest infestations, or structural hazards are also considered to have an unmet housing need—unless they explicitly select “none of the above.”
These questions provide critical clinical insight. It reveals more than housing status—it uncovers instability, vulnerability to displacement, and structural insecurity, all of which have direct implications for medication adherence, nutritional access, sleep quality, and mental health.
Environmental risks such as lead exposure, mold, and inadequate heating are directly associated with adverse health outcomes. Lead is linked to neurodevelopmental delays, particularly in children. Mold exposure worsens respiratory illnesses like asthma. Insufficient heating increases the risk of hypothermia and respiratory infections, especially among older adults and individuals with chronic disease.
Together, these questions provide a concise but comprehensive snapshot of an individual's housing status, allowing healthcare teams to better identify and address one of the most fundamental social determinants of health.
Food Security
We now shift our focus to another critical dimension of health equity: food security—an area that directly impacts nutrition, immune resilience, mental health, and overall patient well-being.
The AHC HRSN Screening Tool includes two validated questions to assess whether individuals and families have consistent access to adequate nutrition:
“Within the past 12 months, you worried that your food would run out before you got money to buy more.”
“Within the past 12 months, the food you bought just didn’t last, and you didn’t have money to get more.”
Responses include:
Food Insecurity
Food insecurity is defined by the U.S. Department of Agriculture (USDA) as the condition in which individuals lack consistent, dependable access to sufficient food for an active, healthy life. Within the CMS Accountable Health Communities (AHC) Model, food insecurity is assessed through a brief, evidence-based screening tool designed to identify unmet nutritional needs among Medicare and Medicaid beneficiaries.
Responses of “often true” or “sometimes true” to either question indicate that the respondent is experiencing food insecurity or is at heightened risk. Identifying this need is critical, as food insecurity has been directly associated with adverse health outcomes, including malnutrition, chronic disease exacerbation, developmental delays in children, and increased healthcare utilization.
Affirmative responses to either question signal a likely unmet need for food assistance.
Clinically, food insecurity is associated with poor glycemic control, increased rates of cardiovascular disease, higher rates of depression and anxiety, and developmental delays in children (CDC, 2024).
Transportation Access
We now shift our focus to another vital dimension of health equity: transportation access—a determinant that profoundly influences timely healthcare utilization, continuity of care, medication adherence, and participation in preventive services.
The screening tool asks:
□ Yes, it has kept me from medical appointments or getting medications
□ Yes, it has kept me from non-medical meetings, appointments, work, or getting things that I need
□ No
Transportation Needs
Transportation barriers refer to the inability to access reliable transit for essential activities, including healthcare visits, work, grocery shopping, and other daily responsibilities. A response indicating any difficulty beyond "no transportation issues" signals a clinically significant need, warranting further evaluation and intervention under the AHC Model.
This single question can explain missed appointments, delayed screenings, and medication lapses.
Utility Access
We now turn to another essential domain of health equity: utility access—a determinant that significantly affects health outcomes through its impact on environmental safety, medication storage, nutrition, and disease management.
Utility Needs
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
□ Yes
□ No
□ Already shut off
Recognizing and addressing utility insecurity is crucial, as inadequate access to heat, electricity, or clean water directly affects patients' ability to maintain health, manage chronic conditions, and live in safe environments conducive to recovery and well-being. Ensuring households have reliable utility services is not only a matter of comfort—it is a critical component of sustaining health and preventing medical deterioration.
Interpersonal Safety
We now turn to another essential domain of health equity: interpersonal safety—a determinant that significantly impacts physical health, emotional well-being, and access to care. Exposure to violence, abuse, or threats within one’s home or community can disrupt treatment plans, deter individuals from seeking timely medical attention, and exacerbate mental health conditions. Ensuring that patients feel safe in their personal environments is foundational to the delivery of ethical, trauma-informed, and effective healthcare.
The screening includes four questions, each designed to identify potential exposure to violence, intimidation, or emotional harm:
Interpersonal Safety
How often does anyone, including family, physically hurt you?
□ Never (1)
□ Rarely (2)
□ Sometimes (3)
□ Fairly often (4)
□ Frequently (5)
How often does anyone, including family, insult or talk down to you?
How often does anyone, including family, threaten you with harm?
How often does anyone scream or curse at you?”
When scored numerically, a cumulative total of 11 or more suggests a potential interpersonal safety concern that warrants further evaluation and intervention (CMS, 2025).
These questions may appear uncomfortable—but they are vital.
Interpersonal violence is a public health crisis with well-documented links to anxiety, depression, substance use disorders, chronic pain syndromes, and other chronic medical conditions. Victims of abuse are more likely to miss appointments, underreport symptoms, and struggle with medication adherence—not because they are noncompliant, but because they are navigating trauma that has yet to be named.
Importantly, the effectiveness of these questions depends on how they are asked—with empathy, clarity, and a plan for support if the answers raise concern.
A positive response must not be met with silence. It must be followed by a trusted referral pathway, trauma-informed care, and interprofessional collaboration with social workers, behavioral health professionals, and community resources.
Interpersonal safety is not just a social issue. It is a clinical concern—and one that no practitioner can afford to ignore. Exposure to violence, abuse, or threats within one’s home or community can disrupt treatment plans, deter individuals from seeking timely medical attention, and exacerbate mental health conditions. Ensuring that patients feel safe in their personal environments is foundational to the delivery of ethical, trauma-informed, and effective healthcare.
Beyond the five core domains, the supplemental domains in the AHC Health-Related Social Needs Screening Tool provide additional layers of insight—capturing often-overlooked barriers to care and well-being. Among the most relevant to clinical encounters are Financial Strain, Employment, Family and Community Support, Education, Physical Activity, Substance Use, Mental Health, and Disabilities —each carrying substantial implications for patient outcomes.
This simple inquiry reveals the invisible weight many patients carry into their appointments—juggling medical advice against unpaid bills, heating costs, or debt. Financial stress is not only psychologically taxing; it has been linked to poor sleep, uncontrolled chronic illness, and delayed care-seeking behavior (Hall et al., 2024).
When a patient cannot afford to follow through with the treatment plan, it is not an issue of compliance. It is a resource constraint, and one that needs to be met with options.
How often do you feel lonely or isolated from those around you?
Do you speak a language other than English at home?
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?
On average, how many minutes did you usually spend exercising at this level on one of those days?
Determining a Physical Activity–Related Health-Related Social Need (HRSN)
To assess whether an individual has an unmet need related to physical activity, follow this two-step process:
These thresholds align with evidence-based physical activity guidelines and are used to identify individuals at increased risk of preventable health conditions due to insufficient physical activity.
Substance Use Screening Introduction
The following questions pertain to your use of alcohol, tobacco, and other substances. Some items listed may include medications that are legally prescribed; however, please only consider those taken in ways other than prescribed—such as in different amounts or for non-medical reasons. One question will address the use of substances that are considered illicit or illegal. We ask these questions not to pass judgment, but to better understand your needs and connect you with appropriate community-based resources and support services, if needed.
How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.
☐ Never
☐ Once or Twice
☐ Monthly
☐ Weekly
☐ Daily or Almost Daily
How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?
☐ Never
☐ Once or Twice
☐ Monthly
☐ Weekly
☐ Daily or Almost Daily
How many times in the past year have you used prescription drugs for non-medical reasons?
☐ Never
☐ Once or Twice
☐ Monthly
☐ Weekly
☐ Daily or Almost Daily
How many times in the past year have you used illegal drugs?
☐ Never
☐ Once or Twice
☐ Monthly
☐ Weekly
☐ Daily or Almost Daily
Mental health, though increasingly addressed in clinical practice, still remains under-screened—especially in non-psychiatric settings. The AHC tool includes this question, adapted from the validated PHQ-2 screener:
“Over the past 2 weeks, how often have you been bothered by any of the following problems?”
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
A combined score of 3 or more suggests a need for further mental health assessment and referral.
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?
As public health data continues to confirm, untreated mental health conditions are associated with worsened physical health, lower quality of life, higher rates of emergency room use, and reduced treatment engagement (National Academies of Sciences, 2024).
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?20 (5 years old or older)
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?21 (15 years old or older)
These assessments play a pivotal role in care coordination.
They provide essential information to guide decisions regarding in-home services, caregiver engagement, transportation assistance, and necessary modifications to improve accessibility and ensure patient safety.
Together, these supplemental domains offer a 360-degree view of health—inviting clinicians to move beyond organ systems and ICD codes, and into the social realities that shape a patient’s ability to heal.
Screening is not just data collection. It is clinical witnessing—a declaration that the healthcare system sees the full person, not just their symptoms.
The AHC HRSN Screening Tool is designed for clinical use at scale. Its 10 core questions can be completed quickly by patients during intake or pre-visit screenings, and it is flexible enough to be integrated into electronic medical record systems and team-based care models. In clinical trials and implementation studies, screening patients with this tool has led to improved care coordination, better referrals to community resources, and a clearer understanding of barriers to adherence (Alley et al., 2024).
More importantly, the tool shifts the conversation.
It moves the patient's encounter from “What’s your problem?” to “What’s in your way?”
Too often, clinicians are asked to manage diabetes without asking if the patient can refrigerate insulin, or to prescribe medication without knowing if the patient can afford groceries. Screening for health-related social needs allows us as clinicians to reconnect medicine to reality.
And the need is urgent. CMS reports that across the 32 participating Accountable Health Communities, more than 7 million Medicare and Medicaid beneficiaries will be screened using this tool over the next five years (CMS, 2025). The tool is being adopted not only by hospitals and primary care practices, but by behavioral health providers, community health centers, and integrated care systems nationwide.
As of 2024, major national organizations—including the National Academies of Medicine, the CDC, and the Agency for Healthcare Research and Quality—recommend the incorporation of social needs screening as a best practice in patient-centered care (National Academies of Sciences, 2024; AHRQ, 2024).
Still, screening is only the first step.
What follows must be a system of referrals, coordination, and accountability—linking patients not just to diagnoses, but to solutions.
To ask about food insecurity without offering pathways to nutrition assistance, or to uncover domestic violence without connecting to support systems, is insufficient. As clinicians, we must ensure that every question leads to an action, every response to a resource, and every barrier to a plan.
So where do we go from here?
1. Medical education must evolve.
Future physicians must be trained not only in foundational medical sciences such as anatomy and biochemistry, but also in the broader social and environmental conditions that influence patient health. Addressing today’s complex healthcare challenges requires an interdisciplinary approach that incorporates housing policy, food security, environmental health, and structural inequities.
While the Association of American Medical Colleges (AAMC) now emphasizes “structural competency,” many medical education curricula still lack formal, longitudinal integration of SDOH. Medical students must not only understand health disparities but also be trained to engage in systems-based advocacy and community-engaged care as integral aspects of modern clinical practice.
There is growing national momentum to integrate public health principles, community engagement strategies, and policy literacy into clinical education to better prepare physicians for the structural realities shaping patient care.
2. Healthcare systems must integrate social needs screenings into routine care.
Health-related social needs (HRSNs)—including food insecurity, unstable housing, and lack of transportation—should be addressed with the same routine and urgency as traditional clinical measures like blood pressure or cholesterol. Evidence from the CMS Accountable Health Communities Model indicates that implementing universal social needs screening alongside structured community referral systems leads to improved patient outcomes and greater healthcare system efficiency.
However, screening for social needs alone is insufficient. For these efforts to be effective, they must be supported by a well-trained workforce, efficient ways to share information across teams, and a sustained institutional commitment to equity—embedded not as a temporary initiative, but as a fundamental component of clinical care. Clinics that serve low-income and rural communities often face serious limitations in funding and workforce capacity, which can result in identifying patient needs without being able to address them. Closing this gap will require long-term federal support, partnerships with academic institutions, and strong local coalitions to turn data into action.
3. Clinicians and healthcare industries must be structurally aware
While empathy remains essential in clinical practice, it must be complemented by structural awareness. Healthcare professionals need to recognize that behaviors often labeled as "non-compliant"—such as missed appointments, medication non-adherence, or dietary lapses—may be rational responses to systemic barriers. For example, a patient prioritizing rent over paying for insulin or missing a doctor’s appointment due to caregiving responsibilities is navigating the challenges imposed by social and economic inequities, not failing or being irresponsible in their own health care. Understanding these behaviors within the context of structural determinants is crucial for delivering equitable and effective healthcare.
4. The public must demand accountability—from institutions, not just individuals.
Health does not begin in the hospital. It begins in the home, the school, the street, and the soil.
Public accountability must extend beyond individuals to the systems and institutions that shape our collective health. Healthcare does not begin within hospital walls—it begins in our homes, schools, neighborhoods, and natural environments.
To advance health equity, policy must be treated as a determinant of health. This includes zoning regulations that safeguard clean air and water; school board decisions that prioritize access to nurses, mental health counselors, and nutritious meals; and transportation policies that guarantee rural residents access to dialysis, prenatal care, and behavioral health services.
🎻 [Closing music: Subtle strings rising—somber, reflective—fading into stillness.]
Health is not merely an individual state—it is a societal mirror, polished by justice or clouded by neglect. It reflects our urban planning, our food deserts, our wage gaps, and our educational inequities. When communities suffer, when structural barriers go unaddressed, the clinic becomes the final stop on a long chain of silent suffering.
If we want to heal bodies, we must also heal the systems that injure them.
This requires more than awareness—it demands action across disciplines. We must teach the next generation of clinicians to see the full patient story, beyond the exam room, embedded in policy, geography, and history. Medical education curricula must evolve to include housing law, environmental justice, trauma-informed care, and public health literacy—because these are the modern determinants of health outcomes.
We must legislate with the body in mind. Paid family leave, rent stabilization, anti-discrimination protections, and transportation equity are not outside the scope of medicine—they are upstream prescriptions for health.
We must listen—not only to biometric data, but to lived experience. Social determinants of health are often spoken in silence: in missed appointments, empty refrigerators, and unanswered calls. It is the physician’s duty to recognize that silence, interpret it, and respond with dignity and resources.
The social determinants of health are not ancillary to medicine. They are its bedrock. Without them, we cannot practice true primary care.
But there is hope. Change is not a concept—it is a competency. It can be taught. It must be expected.
Before we part, I offer my deepest and most reverent gratitude:
To my beloved family—Your love is the foundation of every truth I speak.
To my loyal friends and unwavering colleagues—Thank you for standing beside me with honor, integrity, and unwavering belief in the importance of telling stories and content that matter.
To my gifted audio and sound engineers—You turn breath into atmosphere. Word into world. Thank you for shaping this podcast into more than sound—for turning it into a sacred space where knowledge and compassion meet.
To my security team - Thank you for guarding the threshold of this mission.
To my secretaries and coordinators—You are the quiet brilliance behind the rhythm of this production.
To my legal team—Thank you for ensuring that every word I speak, every script I write, and every insight I share is protected with the full weight of watermark, authorship, and law.
And most of all, to you—
Our global audience of listeners, learners, clinicians, scholars, and seekers.
Thank you for believing that health is more than diagnosis, that healing requires story, and that medicine must meet the world as it truly is.
Until our next chapter in Secrets of Survival (SOS),
May you breathe with awareness,
May you practice with courage,
And may you carry this blueprint of wellbeing into every corner of the world you touch.
With all my gratitude,
I’m Dr. Susan Rashid.
Thank you for joining me.