Learn The Lingo

Learn the Lingo: Key Terms for Navigating the Value Based Care World

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG.

Angel Baltimore
/ Categories: Learn the Lingo

Social Determinants of Health (SDOH)

Definition: According to CDC, SDOH are “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks [sic] and outcomes.”1 These factors can impact patient access to and understanding of health care. They may also impact the extent to which a patient or population is able to engage in their health care and healthy living.

The 5 determinants of SDOH, as recognized by Healthy People 2020, include 2

  • Economic stability
    • employment/income, cost of living, socioeconomic status/poverty, food security, housing stability
  • Education
    • high school graduation, enrollment in higher education, language and literacy, early childhood education and development
  • Social and community context
    • social support, civic participation, discrimination, workplace conditions, incarceration2
  • Health and health care
    • access to health care, insurance coverage, health literacy, access to primary care
  • Neighborhoods and built environment
    • access to transportation, availability of healthy foods, quality of water or air, neighborhood crime and violence, quality of housing

How it relates to ACO/PCMH: ACOs work to coordinate high-quality care for patients. Frequent contact with patients offers opportunities to assess patients’ SDOH and address any barriers or needs. Health care practitioners, including pharmacists, can apply their expertise and the available resources to support patients in improving individual and population health and increasing health equity. When pharmacists help a patient get answers to their questions or health concerns, help patients get transportation to and from appointments, assist in requesting referrals or orders, connect patients with community resources, or take action to address gaps in care, they are helping patients succeed as well as receive the care they need. Some electronic health records have built-in assessment tools that can help identify an individual patient’s barriers, such as lack of understanding, lack of resources, or lack of motivation due to external stressors or struggles. By assessing SDOH, pharmacists and other health care practitioners can best identify how to support the patient, what resources to offer, and how to improve the patient’s engagement in their health care. By collaborating within the ACO with providers, and with communities, pharmacists can improve the quality of services, develop solutions, and develop or influence policies that improve population health.

Involved organizations/oversight: Healthy People 2020, CDC, World Health Organization


  1. CDC. Social determinants of health: know what affects health. Available at:
  2. Office of Disease Prevention and Health Promotion. Social determinants of health. Available at:
  3. WHO. Social determinants of health. Available at:

Contributing authors:

Cara Acklin, PharmD, BCACP
ACO Pharmacy Manager Franciscan Alliance

Heather DeYoung, PharmD
PGY-2 Ambulatory Care Franciscan Health Hammond

Last Updated 4/9/2020

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