In the complex world of behavioral healthcare, where patients often require support from a diverse range of professionals, electronic health records (EHRs) play a critical role in improving care coordination. While more EHRs have begun to support collaboration among psychiatrists, psychologists, social workers, substance use counselors, primary care physicians, and providers, the next frontier is integrating Social Drivers of Health (SDOH) data into these systems to facilitate the delivery of truly comprehensive and holistic behavioral healthcare. 

SDOH—also referred to as social drivers of care—encompass factors like housing stability, food insecurity, employment status, education, access to transportation, and social support networks. Research consistently shows that up to 80% of health outcomes are influenced by these social drivers, rather than clinical care alone. For patients with behavioral health conditions, where mental health, substance use, and adherence to treatment plans are deeply intertwined with life circumstances, integrating SDOH data into EHRs can be transformative. 

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How SDOH & EHR Integration Improves Behavioral Healthcare 

Accessible EHRs allow providers to access a patient’s complete health history, facilitating timely and informed decision-making—preferably at point of care. When combined with SDOH data, these become clear insights into the patient’s circumstances and offer a more holistic view of their life. This helps providers design actionable treatment plans that address not only clinical needs but also the broader social and environmental factors that influence health. Here are a few scenarios where this integration makes a significant difference: 

Addressing Housing Instability:

If a client struggling with homelessness or financial insecurity cannot attend appointments or afford medications, a provider informed by SDOH data can connect them with social services, housing support, or financial assistance programs.

Supporting Employment Needs:

A client with depression who is also dealing with unemployment might benefit from vocational rehabilitation services alongside therapy and medication. If this social driver is captured in the EHR, it ensures the care team can coordinate with external resources to support the client’s overall well-being.

Overcoming Transportation Barriers:

A substance use counselor might not realize that a client’s missed appointments are due to a lack of reliable transportation. When this information is documented in the EHR, the counselor can work with a case manager to find solutions, such as transportation vouchers or telehealth options, to improve treatment adherence.

Tackling Underlying Issues:

Individuals experiencing chronic stress due to social drivers are at higher risk for anxiety, depression, and substance use. But without knowing these root causes, clinical interventions may only provide short-term relief. Integrating SDOH data into EHRs allows providers to take these broader life circumstances into account when designing treatment plans, ensuring that care is more personalized and targeted.

In traditional healthcare models, services are often fragmented, with providers unaware of the non-clinical challenges a patient may face. As these examples demonstrate, by integrating SDOH data into EHRs, all providers involved in the patient’s care can access a shared, comprehensive understanding of their needs, ensuring more effective interventions. 

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Beyond Individual Care: The Broader Impact of SDOH Integration 

Integrating SDOH data into EHRs is not only beneficial for individual patient care but also supports population health management. Health systems can analyze aggregated data to identify high-risk populations or geographic areas where social drivers are negatively impacting behavioral health outcomes. This information can guide public health initiatives, resource allocation, and policy decisions aimed at reducing health disparities. A few examples: 

Expanding Access to Resources:

If EHR data reveals that a large proportion of patients in a specific community are experiencing food insecurity, organizations can collaborate, for example, with local food pantries, elected officials and government agencies to develop targeted interventions aimed at reducing food scarcity. This could involve creating partnerships to expand access to food assistance programs, including SNAP, the Emergency Food Assistance Program, and the National School Lunch Program, as well as connection to food pantries or establishing food as medicine programs. 

Identifying Risk Factors:

Individuals facing job loss or social isolation are more likely to experience a mental health crisis or relapse in substance use. EHR systems that capture these risk factors can flag clients for early intervention, such as increased counseling sessions, crisis intervention planning, or referrals to social services. This proactive approach can prevent costly hospitalizations and improve the overall quality of care. 

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EHRs in Action: Key Features that Enable SDOH Integration  

To bring these ideas to reality, here are some ways that EHRs can enable providers to capture, monitor, and act on SDOH data: 

Customize Screening Tools:

Leverage tools that allow providers to assess things like housing, employment, transportation, and other social needs directly within the EHR system at intake. Examples could include the CMS Innovation Center’s Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool or the National Association of Community Health Centers’ Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences tool (PRAPARE). 

Simplify Referral Pathways:

Integrate referral and tracking tools that help behavioral health providers connect with local housing services, employment programs, and other social services organizations, and track whether referral services were accessed in order to close the loop. 

Embed SDOH in Care Plans:

Support the inclusion of SDOH data in personalized care plans, so providers can address both clinical and non-clinical factors in treatment plans. 

Facilitate Real-Time Data Sharing:

Enable secure data exchange between behavioral health providers and community partners to ensure that all parties involved in the client’s care are aware of their social context. This enables more coordinated care and quicker interventions. 

Measure SDOH as a Quality Care Metric:

Assist providers in capturing and reporting on measures that show how addressing SDOH can lead to increased adherence and follow-up, reduced ER visits and hospital readmissions, or improved mental health outcomes. 

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Shifting to a Holistic Model of Behavioral Healthcare at the Intersection of EHR & SDOH 

Incorporating social drivers of care into EHRs is essential for transforming behavioral health care from a reactive, crisis-driven model into one that is proactive, coordinated, and holistic. It ensures that providers are not just treating symptoms but addressing the full spectrum of factors that influence a patient’s health.  

This approach promotes better outcomes, reduces healthcare disparities, and fosters a more integrated and client-centered system of care. By capturing and acting on SDOH data, EHR systems can facilitate the delivery of truly comprehensive behavioral healthcare. 

Want to learn more about how accessible EHRs that incorporate SDOH data and other critical information are transforming behavioral healthcare? Watch our webinar, “Empowering Patients with Accessible EHRs: Q&A with Dr. Jorge Petit” to hear from our Chief Clinical Advisor.