Overview
Unmet social needs can harm patients’ health. Patients may need assistance with food, housing, transportation, employment, budgeting, and legal matters. Linking patients with available community resources helps reduce barriers to good health and furthers health equity. To help patients navigate their way to assistance, practices can learn about the resources available in the community, be sensitive and caring when asking about social needs, direct patients to resources, and follow up to ensure that the connections are, in fact, made. In addition to helping your patients achieve better health, you may benefit financially if you receive payments based on measures of patient outcomes or incentives for screening for and attending to social needs. Having a way to link patients with community resources can also reduce care team stress and burnout.
TIP
Attending to patients' social needs is not simple. Patients may be hesitant to share information about their social needs. Find additional resources in the appendix to help you prepare: Additional Resources for Attending to Social Needs.
Actions
Consider who in the practice will work on assisting patients with social needs.
- Decide whether existing staff can take on new roles. Are there people in the practice who can conduct assessments, identify and update community resource lists, establish relationships with community organizations, help with applications for assistance, refer and follow up with patients, and review aggregate data?
- Explore options for augmenting staff. For example, could you share a community resource specialist with other practices? Is there someone in the community who plays that role that you could partner with?
Decide which social needs to screen for and which screeners to use.
You can take an incremental approach and screen for one or two social needs, then add others as resources become available. Food, housing, and transportation are common priorities.
- Use community health assessments and talk with advisors from the community to find out which needs are most urgent in your area.
- Think about how you will use the information when deciding what information to collect. You might use the information for:
- Patient care. Responses to positive screens include education and counseling, assistance, and referral. In addition, clinicians could use screening results to engage patients in shared decision making and help them choose treatments that are a good fit for them. Screening results could also trigger conversations about healthcare costs. Go to Tool 23: Talk Â鶹´«Ã½ Costs to learn more.
- Population health. Aggregate data on your patients’ social needs will help you select the types of assistance and referral arrangements to put in place.
- Advocacy. Documenting unmet needs can help with advocating for more resources for your community. It can also help with advocacy within your organization for attending to social needs.
- Consider using standardized screening questions. You can find links to tools and guides on screening for social needs in the appendix, Additional Resources for Attending to Social Needs. Check if your electronic health record (EHR) has embedded social needs screeners.
- Check requirements and recommendations for social needs screening. More organizations such as State Medicaid agencies, Medicare, commercial health plans, and accreditors (e.g., The Joint Commission, NCQA) are promoting or requiring screening.
Decide whom to screen, how, and how often.
- Decide which patients to screen. While assessing the needs of all patients is ideal, you might want to start with certain populations. For example, patients with diabetes are often a priority due to the impact of food insecurity on their condition.
- Choose how to administer the screener. Identifying and Addressing Social Needs in Primary Care Settings discusses the tradeoffs between self-administered and staff-administered screening, as well as between on-site and at-home screening.
- If screeners are staff-administered, train staff in skills to build trust with patients, such as using active listening, empathetic inquiry, cultural humility, and trauma-informed and asset-based approaches. People conducting social needs assessments should be aware of conditions in the community and their own potential biases about who they think needs help. Training can ensure that social needs are assessed in a way that is sensitive and does not stigmatize anyone.
- If the screening takes place on site, make sure it is done in a private space. Give patients the choice of excluding companions from the screening discussion.
- If screeners are self-administered, make sure the screener is in plain language and available in the languages your patients read.
- If on site, offer to read the screener to all patients.
- If patients complete screeners at home, provide a phone number they can call to get help completing it.
- Screen for social needs at least once a year. Social needs can change quickly, so consider which patients you might want to screen more often.
Identify your community resources.
- Work with community leaders to find out about resources.
- Use social health referral platforms, such as , , and to find resources near you. Find more resources in the appendix, Additional Resources for Attending to Social Needs.
- Partner with community organizations. Establish referral agreements with community service providers so they accept your referrals and let you know when the referral is completed. This between a food bank and a health clinic is an example. Go to Tool 21: Make Referrals Easy for information on establishing referral agreements, and on supporting and following up on referrals.
- Keep resources up to date. Ask patients to let you know if they cannot reach a community resource or have a negative experience. Establish a schedule for verifying whether resource information is still accurate.
Assess patients' social needs and support systems.
- Explain why you are asking questions about their social needs, who will see the information, and how you will use it. This may overcome feelings of shame or fear that the information will be used against them (e.g., reporting their housing instability to child protective services).
- Find out if any social needs are urgent. If they screen positive for any social needs, it is important to know how quickly they need help.
- Consider asking patients open-ended questions about things that may affect their ability to manage their health. For example, you could ask, "Is there anything in your daily life that makes it hard to take care of your health?"
- Ask about and involve the patient's current support systems, such as family, friends, social workers, and care managers. Find out and note in the medical record the role each member of the support system plays in the patient's care. Never contact members of the support network or share information without the patient's explicit permission. Be aware that some information may be difficult for family members or friends to hear about.
- Document patients' social needs and support system in your EHR. Use . Establish a place in the EHR to document other social needs and social support, and make sure everyone in the practice documents in the same way.
Connect patients with resources.
- Ask patients if they want information, resources, or to be referred to community organizations. Patients may not want or need help at that time or may distrust organizations they do not know. If patients screen positive for multiple social needs, help them prioritize.
- Make a referral. Two methods of referral are:
- Direct referrals. You may be able to send an electronic referral from your EHR or other online platform. If not, you can call the agency, preferably in the presence of the patient. Give patients a Community Referral Form to record the details.
- Self-referral. Patients may choose to contact the organization later. Give them a Community Referral Form to provide essential information about available services.
- Help patients apply for benefits or services. If an application is required to receive benefits or services, offer help in completing it. Find out about community agencies, community health workers, and case workers that can help people with applications for public assistance, public housing or housing subsidies, food aid, or other services. Also check the appendix Resources for Financial Assistance for Medicine for services that assist with medicine costs.
- Follow up. Find out if the referral was completed by contacting the service provider. Document the outcome in the patient’s record. Go to Tool 6: Follow Up with Patients for more information about different ways to follow up.
TIP
Certify a Notary Public. Select one person in the practice to become a Notary Public. This can help expedite completion of application forms and eliminate an additional step for patients. The following link provides access to a .
Track Your Progress
Periodically test whether your resource list is up to date. Call four randomly chosen service providers and verify their information.
Review 10 records of patients who are supposed to be screened for social needs. Check:
- Were patients screened at least once in the past year?
- Were patients’ support systems recorded in the right place?
- Did patients who screened positive for at least 1 social need receive a response (e.g., education, counseling, assistance, or referral) within 30 days of the positive screen?
- Was the outcome of a referral made at least 1 month ago documented in the record?
Repeat in 2, 6, and 12 months.
Before implementing this tool and 2, 6, and 12 months later, collect patient feedback on a selection of questions about this tool from the Health Literacy Patient Feedback Questions.
Refer to Tool 2: Assess Organizational Health Literacy and Create an Improvement Plan to learn how to use data in the improvement process.