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HSR&D In Progress

March 2022

In This Issue: HSR&D Research on Social Determinants
» Table of Contents

Social and Behavioral Determinants of Health in High-Risk Veterans

Feature Article

Takeaway: This study will generate recommended social determinants of health (SDH) measures for universal screening within VA, particularly to identify Veterans disproportionately affected by SDHs. Coupled with qualitative interviews about implementation challenges, these findings will inform the future integration of patient-reported SDH measures into VA’s electronic health record.

Social factors exert a powerful impact on an individual’s health, especially among disadvantaged populations that include many Veterans using VA healthcare. Adverse social determinants of health (SDH), such as housing instability, food insecurity, social isolation, and transportation barriers are linked to problems with access, poorer clinical outcomes, and increased healthcare costs. Despite the clinical and business case for integrating SDHs into healthcare, these factors are not systematically assessed or addressed in clinical settings.

This ongoing study (October 2021 – September 2025) will leverage a previous survey of Veterans at high-risk for hospitalization—and a new survey to a nationally-representative sample of Veterans—to determine how SDHs influence clinical, healthcare use, and experience outcomes. This study also will examine the prevalence of SDHs in sub-populations of Veterans who are disproportionately affected by disparities (e.g., women, racial/ethnic minorities, and rural Veterans). In addition, investigators will identify measures that are associated with key outcomes and that are perceived by operations partners as actionable (i.e., addressable through VA or community services) and, thus, are good candidates for integration into VA’s electronic health record (EHR). This study will be conducted with operations partners from VA’s Offices of Primary Care, Health Equity, Rural Health, and Women’s Health.


Using data from a survey of 4,685 Veterans at high-risk for hospitalization that was conducted in 2018 by VA’s Office of Primary Care, investigators will examine the association between patient-reported SDHs and utilization (i.e., VA and Medicare emergency department visits and hospitalizations), VA and Medicare costs, and days in the community. Using data from a similar survey to a nationally representative sample of Veterans, they also will evaluate the association between SDHs, patient experiences (e.g., perceived access and coordination), and 12-month VA emergency department visits, hospitalizations, and costs to describe the prevalence of SDHs in the general VA population and Veterans who are at risk for health disparities. Working with key stakeholders to prioritize actionable SDH measures for EHR integration, they will then conduct qualitative interviews with health system leaders, clinicians, staff, and patients to examine implementation barriers and facilitators to assessing select SDH measures at point-of-care.


None to report at this time.

Anticipated Impact

 Donna Zulman, MD, MS Donna Zulman, MD, MS

 Matthew Maciejewski, PhD
Matthew Maciejewski, PhD

A review of findings by key stakeholders will generate recommended SDH measures for universal screening within VA. These steps, coupled with qualitative interviews about implementation challenges, will inform the future integration of high-value patient-reported SDH measures into VA’s health record.

Principal Investigator: Donna Zulman, MD, MS, is part of HSR&D’s Center for Innovation to Implementation (Ci2i): Fostering High-Value Care, Palo Alto, CA. Matthew Maciejewski, PhD, is an HSR&D Research Career Scientist at the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC.


Blalock D, Maciejewski M, Zulman D, et al. Subgroups of high-risk Veterans Affairs patients based on social determinants of health predict risk of future hospitalization. Medical Care. May 1, 2021;59(5):410-417.

Zulman D, Maciejewski M, Grubber J, et al. Patient-reported social and behavioral determinants of health and estimated risk of hospitalization in high-risk Veterans Affairs patients. JAMA Network Open. October 1, 2020;3(10):e2021457.

View study abstract

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