There is growing awareness of the impact of upstream social determinants on population health, but until recently these have been considered best addressed by policy makers on a large scale, and beyond the control of the medical system to influence.  That view may be changing, as discussed in this article by Ravi Narayanan, a member of the HIMSS Clinical & Business Intelligence Committee, and a Data Strategy and Management Consultant.  Mr. Narayanan describes how the adoption of value-based care and population health management has led health care providers to incorporate addressing unmet social needs into the provision of medical care.  This article discusses an innovative approach to incorporating social determinants data into population health, through geocoded address data to integrate Community Vital Signs, publicly available data about the community in which the patient lives.