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The CARD Initiative: Equipping Clinicians to Navigate Social Determinants of Health
Mindy Hoang, MD, discussed Wayne State University’s program to help clinicians understand and address underserved patients’ potential social needs.
Some of the largest determinants of health are social and include factors like housing, food access, income, and immigration status. These factors limit the benefits that medical treatment can offer, especially in under-resourced settings, proving a frustration for many clinicians.
Clinicians at Wayne State University in Detroit recognized that understanding how social determinants affect care can help to respond more effectively to these patients' circumstances and started the Community Aid and Resource Distribution (CARD) initiative to this end. Mindy Hoang, MD, a first-year resident at Wayne State, presented the CARD initiative at the American College of Physicians (ACP) Internal Medicine (IM) Meeting 2025, held April 3-5, in New Orleans, Louisiana. HCPLive spoke with Hoang to learn more about the CARD initiative and its reception so far. She also discussed how other centers can use it as a model and shared advice for clinicians looking to engage more with their patients’ social needs.
HCPLive: Can you give some background on CARD and why it's important to look at social determinants of health?
Mindy Hoang, MD: We started CARD because we felt like a lot of our residents were getting overwhelmed with the number of social needs our patients have. And they weren't overwhelmed by addressing the social needs, but more by the lack of resources we have to address them.
No one ever teaches you how many social needs your patients will have. When I talk to other residents, it’s about a third of patient visits that center around these social needs. Sometimes, you can’t help a patient with their asthma if they're stuck in a place where they’re breathing in black mold. Or they can’t move because they can’t meet the income requirements or pay a security deposit.
A lot of our residents were feeling frustrated, so we created a touchpoint to give residents a quick and easy booklet to share with patients. They can look at specific resources too. Say they need medication assistance—they look at the Medication Assistance tab. If they need housing assistance, they check the Housing Assistance tab.
We recognize that this isn’t a permanent or long-term solution for everyone. We feel the answer is integrating community health workers and social workers into primary care settings. But this works great if you don’t have a ton of social resources, like our clinic.
We’ve been doing this for 3 years and we feel it’s been pretty positive overall. I took over the data analysis because the residents who started this project have left. The only thing is, it's really hard to integrate it with our busy resident schedule. Short-term memory is a real thing at our institution, especially if we don't have a lot of residents who recognize the importance of CARD. We have many internal medicine and med-peds residents, and not all of them know what CARD is.
Seniors are often tasked with mentoring first-years. So, if they don’t know about CARD, or forgot about it, or missed the clinic huddle where we talked about it, they’ll forget to use it. Our new initiative is to be at every clinic huddle for the first 3 or 4 months, to talk about CARD and explain why it’s a good resource. Especially since many of our new interns are already asking about social needs—“My patient needs this, but I don’t know how to get it”—this helps us walk through the resources. That’s been our biggest challenge. But everyone has been really positive. It’s helped a lot on the floors, in clinic, and even when residents go off-site.
We have lanyards with QR codes. We also have pamphlets and stickers on our WOWs and every computer in the workstation. And we have a big QR code in all our patient rooms, so everyone remembers these are the resources. If patients are bored, they can look at it too.
Could other centers benefit from your model?
Hoang: We feel like this could be a very good solution if you’re in a low-resource, low-income setting—especially if you don’t have a lot of resources like us. This might be something to duplicate to give other physicians—whether residents or practicing doctors—a good resource to touch base with. It’s also really accessible. We update it every 3 to 6 months to make sure the resources we link are still active and still accepting patients. I think it’s very applicable to low-resource settings. And it’s free to do, too. It doesn’t take too much time.
We partnered with the School of Social Work to create ours. If your clinic isn’t partnered with a social work school, that’s okay. There are local county health departments, local community health workers. Our next project is integrating a community health worker. We’ve realized that screening for social determinants is very difficult in our clinic, especially with how limited our appointments are. So we’re setting up a community health worker initiative. We feel like this will strengthen our relationship with the community because we’re bringing in two health workers from the surrounding area. It’ll also help reduce physician burnout.
Any other social health needs priorities you'd like to tackle?
Hoang: We also have a project on health equity cases. These are cases that involve complex social issues—unfortunately, many of our patients deal with those. Residents in our program submit cases to the Health Equity, Justice and Medicine Initiative. They send them to all specialties to figure out: what should we do for this patient? Is there an unknown resource or a program—like, say, at the cancer center—that could help them?
One recent case was a kid with type 1 diabetes who is undocumented and couldn’t get insulin. We devised a solution where he goes to the emergency department for an emergency visit—they don’t admit him, but they give him insulin. It’s complicated, but it’s the best we can do for now.
With your experience helping patients with many social needs, do you have any advice for clinicians who don’t see this often but may encounter patients with these social needs?
Hoang: For me—I'm not from Detroit and didn’t know the resources either. The best place to start is a community center. Find one in your city or town, and ask what people do when they face a housing crisis or trouble affording meds. When I started, I got involved with a free Spanish-speaking clinic at our affiliated medical school. From there, I found out there were more resources for Spanish speakers and undocumented immigrants. I talked to the clinic coordinator and was like, okay, we can maybe use some of these in our clinic too.
Also, just talk to people outside of medicine. Medicine has gotten more complicated, especially with social determinants of health. Only about 30% of health happens in the clinic—the other 70% is influenced by everything else. Talk to community leaders. Talk to your neighbors. It’s hard, especially in small town, probably harder than in a big city to access all of this. That’s not to say there aren’t resources—it just might take more digging.
I think the last thing I’ll say is that our group believes social determinants of health should be addressed through a multidisciplinary approach. That’s where medicine is going—creating more comprehensive care plans. It’s not just on physicians to ensure patients get the best outcomes. We have to work together.
This transcript has been edited for clarity. Hoang has no disclosures to report.
