Healing beyond hospital walls: Transforming care by addressing Social Determinants of Health

Health is shaped far beyond the walls of hospitals and exam rooms, by the conditions in which people live, work, and age. According to the Centers for Disease Control and Prevention, up to 80% of health outcomes are influenced by factors outside of a physician's office. These external factors - known as social determinants of health (SDOH) - include access to food, stable housing, transportation, education, and social support, and play a substantial role in shaping disparities in health outcomes across communities.

Alongside SDOH, upstream drivers of health, including the systems, policies, and structures that shape social conditions, play an equally critical role in determining outcomes. Addressing both upstream drivers and the resulting SDOH is essential to delivering compassionate, personalized care and improving health outcomes. By combining immediate support for identified patient needs with longer-term efforts to address systemic barriers,Ascension is better able to meet patients where they are.

Using Data to Identify Patient Needs

Since 2020, Ascension has implemented SDOH screening tools across all care sites, prompting patients to complete the questionnaire annually. These screenings are designed to identify potential barriers to health by asking about key areas such as food insecurity, housing stability, transportation access, financial need, and social isolation.

As of fiscal year 2025, Ascension has conducted more than 4.9 million SDOH screenings, including nearly one million re-screenings to better understand how patient needs evolve over time. Insights from this data have identified key drivers of health-related barriers across Ascension's communities. The most immediate priorities are food access, transportation, and medication affordability.

From Data to Action

Building on these insights, Ascension teams are developing programs and processes to connect patients to community resources, along with partnerships that address the most pressing needs while supporting broader organizational goals.

Examples include:

Partnering with Lyft

Ascension data consistently shows that transportation plays a critical role in health outcomes. Limited access to reliable transportation can delay or prevent care, particularly prenatal visits, leading to increased risks for both maternal and infant health, as well as higher overall healthcare costs. Through its partnership with Lyft, Ascension is helping address this barrier. In 2025 alone, Ascension invested more than $1.6 million to provide over 80,000 rides across its ministries.

Neighborhood Resource

Since 2021, Ascension's Neighborhood Resource platform has connected more than 500,000 patients and community members to local organizations offering free or reduced-cost services. By simply entering a ZIP code, users can access a comprehensive database of vital services such as shelters, legal aid, health services, employment assistance, and transportation available in their area.

Community Health Ministries

Ascension's Community Health Ministries (CHMs) serve populations in need by establishing essential health clinics in areas with limited access to care and no other Ascension clinical presence. Ascension operates five CHMs across four states, offering food pantries, primary care clinics, social services, and school-based programming.

Dispensary of Hope and Ascension Rx

As Ascension's dedicated pharmacy, Ascension Rx is a cornerstone in delivering medications where they're needed most - offering convenience, care coordination, and accessibility.

Ascension provides uninsured and low-income individuals with access to essential medications through Ascension Rx, together with Dispensary of Hope, a national nonprofit medication distributor that supplies donated medications to pharmacies and other partner sites, enabling access for those in need at no cost.

Across Dispensary of Hope's nationwide network, including 34 Ascension Rx sites, more than 3,500 prescriptions are dispensed each day.

Food Strategy

As part of the White House's National Strategy on Hunger, Nutrition, and Health, Ascension is working to expand screenings, strengthen community partnerships, and increase access to nutritious food across the communities it serves. In 2024, Ascension was one of 14 health systems selected to support this national effort and is on track to impact four million individuals by 2030. While guided by systemwide priorities, food access initiatives are implemented at the local level, with each ministry developing targeted programs to meet the unique needs of its community.

A Continued Commitment

Ultimately, the goal is to improve health outcomes in the communities Ascension serves, both now and over the long term. Through the continued collection and analysis of SDOH data, Ascension is working to better understand patient needs and translate those insights into meaningful action.

While this work has already led to the development of targeted programs and partnerships, it is just the beginning of our efforts to deliver more personalized care for patients facing additional barriers to health.