A new scoping review published in BMC Public Health is drawing attention to a major shift in how American healthcare organizations understand their role in improving health: hospitals and health systems are increasingly expected to address not only medical conditions, but also the social and digital forces that shape whether people can obtain care, follow treatment plans, and remain healthy. The study examines how healthcare leaders and organizational stakeholders describe this responsibility and compares those perspectives with the types of equity-focused initiatives health systems are actually implementing. Its central message is striking: healthcare organizations are taking action, but most efforts remain concentrated close to the clinical setting, while deeper interventions aimed at changing policy, economic conditions, and community infrastructure are still relatively uncommon.
The researchers focused on Social and Digital Determinants of Health, or SD-DOH. Traditional social determinants include housing stability, food access, transportation, employment, education, neighborhood safety, and social connection. Digital determinants add another layer, including internet availability, device ownership, digital literacy, access to telehealth, the usability of online patient portals, and the ability to navigate increasingly technology-dependent health systems. These factors can determine whether a patient receives an appointment reminder, completes a telemedicine visit, finds trustworthy health information, or remains connected to clinicians after leaving a hospital. As healthcare rapidly adopts artificial intelligence, remote monitoring, online scheduling, and virtual care, unequal digital access can amplify existing racial, geographic, economic, and age-related disparities.
To investigate how organizations respond, the team conducted a PRISMA-ScR-guided scoping review and qualitative evidence synthesis. The researchers searched PubMed, Scopus, ProQuest, and CINAHL for U.S.-based peer-reviewed and gray literature published from January 2020 through June 2025. They identified 94 sources that described the perspectives of healthcare leaders or other organizational stakeholders on responsibility for addressing SD-DOH. Rather than treating responsibility as a single activity, the researchers analyzed the literature through two complementary frameworks: four strategic levers used by health systems and an expanded version of the National Academy of Medicine’s five-part social care framework.
The four strategic levers represent different levels of intervention. Enabling services are downstream activities delivered directly to patients, such as screening for social needs, providing transportation assistance, connecting people with food resources, or supporting digital access. Community partnerships operate at a midstream level, linking hospitals with community-based organizations, schools, local agencies, and public health departments. Policy advocacy is an upstream strategy that seeks to influence laws, regulations, reimbursement systems, and public investment. Direct community investment is another upstream approach, in which healthcare organizations commit financial resources, infrastructure, or institutional assets to address the conditions producing poor health. Together, these categories allowed the researchers to distinguish between helping individuals navigate existing barriers and attempting to reduce or remove the barriers themselves.
The second framework describes how organizations conceptualize their responsibilities. Awareness involves identifying patients’ social and digital needs, often through screening, electronic health record documentation, or community health assessments. Assistance means connecting individuals with services or resources. Adjustment refers to modifying clinical practices, communication, or care delivery to accommodate patients’ circumstances. Alignment involves coordinating healthcare organizations with community partners and broader systems. Advocacy describes efforts to influence public policy and structural conditions. The researchers added a sixth category—system governance and accountability—to capture leadership structures, performance measurement, institutional oversight, and mechanisms that make equity an organizational obligation rather than an optional project.
The results reveal a clear imbalance in the current landscape. Enabling services appeared in 86% of the initiatives identified in the literature, making them by far the most common form of equity-oriented action. Community partnerships followed at 70%. By comparison, policy advocacy appeared in 34% of initiatives, while direct community investment was present in only 9%. The pattern suggests that many health systems are willing to help patients manage immediate obstacles, but far fewer are consistently investing in or challenging the systems that create those obstacles. In practical terms, a hospital may help a patient arrange transportation or enroll in a food program, yet stop short of using its political influence or financial resources to address inadequate transit, food insecurity, broadband gaps, or unstable housing at their source.
The responsibility perspectives found in the literature were also multidimensional. Alignment was the most frequently observed perspective, appearing in 83% of the sources or initiatives analyzed. Assistance appeared in 68%, Adjustment in 65%, Awareness in 61%, and system governance and accountability in 60%. Advocacy was least common, appearing in 32%. This ordering suggests that healthcare leaders often see collaboration and coordination as central responsibilities, while direct political engagement remains more difficult to institutionalize. Alignment may include formal partnerships with community-based organizations, referral networks, shared care plans, joint health assessments, and coordinated responses to local needs. However, collaboration alone does not necessarily redistribute power or funding, and the review indicates that partnerships are most effective when supported by governance systems that clarify roles, measure outcomes, and sustain accountability.
The strongest connections between responsibility perspectives and strategic action appeared where organizations were closest to patient care. Assistance and Adjustment were each associated with 98% of enabling-service initiatives, showing that direct support and flexible care delivery tend to develop together. Alignment appeared in every community-partnership initiative and every direct-community-investment initiative, as well as in 83% of enabling-service initiatives. The relationship between Advocacy and upstream work was especially pronounced: Advocacy appeared in 88% of direct-community-investment initiatives, but in only 25% of enabling-service initiatives. System governance and accountability acted as a bridge across all four levers, appearing in 100% of direct-community-investment initiatives, 75% of policy-advocacy initiatives, 56% of community partnerships, and 54% of enabling-service initiatives.
The authors interpret these findings as evidence that U.S. health systems may be approaching an inflection point. Governance and accountability are already present in a substantial share of initiatives, meaning that organizations may possess some of the institutional tools needed to move beyond isolated programs. Those tools can include executive oversight, equity metrics, board-level reporting, community benefit requirements, dedicated budgets, workforce training, and integration of social and digital needs into electronic health records and quality-improvement systems. The challenge is converting recognition into durable organizational behavior. If equity goals are not linked to funding, leadership evaluation, clinical performance measures, and transparent reporting, they can remain vulnerable to changing priorities and short-term grants.
The review also suggests that policy advocacy may be a realistic next step for organizations that have already developed strong partnerships and internal alignment. Healthcare systems are among the largest employers and economic institutions in many communities, giving them potential influence over broadband expansion, housing policy, transportation, food access, Medicaid reimbursement, digital inclusion, and public health funding. Yet the researchers caution, implicitly through the evidence, that upstream responsibility should not replace direct services. Patients facing immediate needs still require practical assistance, while long-term improvements demand coordinated action across healthcare, government, business, education, and community organizations. The emerging model is therefore not a choice between treating individuals and changing systems, but a progression in which patient support, community alignment, governance, investment, and advocacy reinforce one another. As healthcare becomes more digital and health inequities remain deeply connected to social conditions, the study argues that responsibility for health can no longer be limited to what happens inside the examination room.
Subject of Research: Healthcare responsibility for addressing social and digital determinants of health in the United States
Article Title: Leader and organizational stakeholder perspectives on healthcare responsibility for addressing Social and Digital Determinants of Health (SD-DOH) in the United States: a scoping review and qualitative evidence synthesis
Article References: Rangachari, P., Thapa, A., Gari, S. N. B., et al. “Leader and organizational stakeholder perspectives on healthcare responsibility for addressing Social and Digital Determinants of Health (SD-DOH) in the United States: a scoping review and qualitative evidence synthesis.” BMC Public Health (2026).
Image Credits: AI Generated
DOI: 10.1186/s12889-026-29142-x
Keywords: Social determinants of health; Social and digital determinants of health; Health system responsibility; Equity-oriented initiatives; Digital equity; Cross-sector collaboration; Shared accountability; Policy advocacy
Tags: community health infrastructuredigital determinants of healthdigital literacy in healthcarehealth disparities reduction strategieshealth equity initiativeshealthcare organizational responsibilityhospital and health system rolespolicy influence on health outcomesSocial and digital health determinantssocial determinants intervention strategiessocial determinants of healthtelehealth access disparities
