Behavioral Health - Key Activity 10


Develop a Social Needs Screening Process that Informs Patient Treatment Plans


This key activity involves the following elements of person-centered population-based care: address social needs.


This activity provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. Social needs are defined as individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being, such as housing, food, clean water and air, sanitation, and social support.

Evidence continues to accumulate that demonstrates not only the ways in which social needs impact physical and mental health outcomes[1][2][3] but also how worsening physical and mental health conditions can impact social stability.[4][5] Unemployment and/or precarious employment conditions are routinely linked to increased psychological distress. Greater levels of homelessness, marital instability, economic insecurity, and incomplete schooling have been associated with worsening control of mental health diagnoses.[6]

Combining workflows for universal BH screening with screening for SDOH will provide some efficiency and also ensure that the care team is aware of various needs. Addressing behavioral health conditions, such as depression, can better equip patients to help them address social needs.

Screening for social needs provides an opportunity to ensure healthcare is provided in the context of life circumstances in which patients and their families are living – part of providing holistic, person-centered care.

Health equity is advanced by addressing the underlying issues that prevent people from being healthy. At the population level, this means addressing communitywide social drivers of health and structural determinants and, at the individual level, this means acknowledging and beginning to address health-related social needs.[7]

Social needs screening often asks questions about private and potentially stigmatized aspects of a patient’s life (e.g., poverty, intimate partner violence).[8] See below about screening for and responding to social needs in a trauma-informed way. Be aware that staff may also experience trauma when screening for social needs (e.g., if a staff person has a history of food insecurity or experiencing homelessness in the past) and have a plan to support staff needs.

Note that there is not yet consensus or uniform endorsement regarding screening for social needs, due at least in part to a lack of high-quality evidence on the risks, benefits, and best practices of screening and response.[9] For example, findings from the recent CMS Accountable Health Communities Model indicate that social needs screening and navigation services reduced ED utilization and may have reduced expenditures but did not appear to increase patients’ connection to community services or resolve patients’ social needs.[10] Other possible ways social needs screening can support attending to social needs include strengthening the patient-provider relationship,[11] destigmatizing social services, tailoring care, and, at a population level, increasing social investment.[12]

Technology-enabled screening can be utilized to screen patients for social needs through various channels: Directly in the EHR, in applications used by care coordinators, and directly to patients via patient-facing inreach and engagement technologies. Practices will need to determine a process to assure that externally generated screening information be incorporated into the patient record and used for care delivery, risk assessment, and management and for managing relevant referrals. Social health information exchanges exist in some communities to identify where patients are getting social services and help identify higher risk patients; these will develop over time.

Action steps and roles

1. Pick a validated standardized screening instrument and establish how to document results.

Suggested team member(s) responsible: Clinical leadership.

Pick a standardized screening tool that fits your organizational environment and the context of your patient population. The Social Interventions Research and Evaluation Network (SIREN) conducted a review of social needs screening tools and provides a comparison and search tool for different tools for adults and children. Currently available standardized tools you might consider include:

Work with your clinical informatics team to determine how staff will document screening results in your EHR. Some EHR systems have screening tools already embedded and many are moving quickly to incorporate screening; some EHRs may be able to auto-populate Z codes based on screening results. Your managed care plans may offer additional guidance or support and can be a resource to connect your practice to other organizations that have experience with screening instruments and technology tools. By using the same screening tools and/or information technology platforms, the consistency and quality of care delivery can be enhanced.

For the patient’s problem list, DHCS provides a list of 25 Priority Social Determinant of Health (SDOH) Codes to focus on. This shorter list of codes is intended to capture areas where the health system may have the greatest impact on identifying and addressing social needs.

2. Understand resources and community referrals for positive screens.

Suggested team member(s) responsible: Referral manager, community health workers.

Through CalAIM, the California Department of Health Care Services (DHCS) has taken steps to ensure that Medi-Cal patients have access to social support that can impact health outcomes. Connect with your managed care plan(s) (MCPs) and regional area consortia to understand what services and resources they have in place to support patient access to community-based social services. Many MCPs are developing relationships with social services agencies to meet the needs of their patients.

For Medi-Cal patients with the highest level of social needs, MCPs offer Enhanced Care Management (see Key Activity 20. Improve Care of People with More Severely Impacting Conditions) and some or all of 14 CalAIM Community Supports: these provide resources to address social needs, such as housing transition navigation, recuperative care post hospitalization, and sobering centers. Some MCPs use the new CalAssist tool for Medi-Cal patients to self-identify whether they are eligible for any of the 14 CalAIM Community Supports and generate a referral to the applicable community support service.

Many patients will screen positive for social needs and will benefit from connection to alternative resources that are not part of Community Supports. Contact your MCP to see if they have established relationships with providers that connect individuals to social services. Health plans may contract with an online provider or with a social services network lead entity that can connect you with existing community-based organizations and public agencies in the area. These contracted services will often include a process for making closed loop referrals, where the referring provider is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination that lead to higher levels of patient and provider satisfaction.[13]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Other places to look to build sources for local community referrals include:

  • Your current social work staff and/or community health workers, who may have many go-to resources already identified.
  • Free online aggregators for local community services in California, such as, a free telephone number providing access to local community services for housing, utility, food, and employment assistance.
  • Resource networks maintained by a local hospital or larger health system in your area.

For going deeper in this area, practices can consider prioritizing quality improvement activities that establish new or previously underutilized community resources to address specific social needs as part of your systematic approach to decrease inequities. Case studies provided in the resources linked below provide examples of these improvement initiatives.

3. Establish a workflow for screening and referrals.

Consider screening before the patient meets with the PCP and have a workflow in place for follow-up of positive screen (e.g., meet with care coordinator or care management staff who will facilitate referral). Take steps to flag the positive screen so the care team is aware and can address any positive screens during the visit.

Train staff in the new workflows and how to provide trauma-informed screening. Staff often initially resist screening if they feel they don’t have the tools to help address positive screens.

  • Following screening, ask patients for their prioritized needs and whether they would like assistance before making a referral.
  • Providing a written script for staff and accompanying signage can build confidence in dealing with the challenging circumstances that many patients experience.


4. Provide person-centered care that acknowledges social needs.

Suggested team member(s) responsible: PCPs and the expanded care team.

Information about a patient’s social needs can be used to provide tailored, person-centered care and treatment plans that patients are more likely to follow. For example, if a patient screens positive for transportation insecurity, this would affect their ability to come in for in-person behavioral health follow-up. Honor the patient’s decisions, including whether and how they choose to address their social needs. See Key Activity 13: Optimize Patient Engagement and Activation for more on co-creating treatment goals with patients, providing self-management support, and using communication techniques, such as motivational interviewing. See resource: Trauma-Informed Population Health Management.

The desires and goals of the patient will inform how and when to move ahead in addressing social needs. It is important to support patients through motivational interviewing and trauma-informed practices to create a person-centered care plan. Having processes in place to support ongoing person-centered care planning, such as a warm handoff to a care coordinator or a documented plan to follow up on specific needs at the next visit, will help to build trust and support a patient’s successful connection to community referrals when they are ready.

Examples of how this activity has been implemented

Rogue Community Health Center in Medford, Oregon, recognized the need to implement screening for health-related social needs. They also recognized that the lack of interoperability of health information flow was a barrier to collaboration in their community. As a result, they served as a convener and backbone partner, pulling together a group of community-based organizations and public health entities into a “no wrong door” model for screening of social needs. The partnership was called the Rogue Challenge and resulted in a shared community database where patients could be screened at multiple data entry points and the life cycle of a positive screen and referral could be tracked to ensure that people with positive screens were connected to community resources and completed their referrals. Together, the collaborating partners selected an appropriate validated social needs screening tool and adapted it to their context. Next, the team tested screening workflows, including the ability to access information and provide additional screens. This approach expanded the capacity of community-based organizations to administer social health screening, which provided the health center with information in advance of a clinic visit. In their value-based care environment, it had the added benefit of identifying new patients not connected to primary care and connecting them to the health center, thus growing their population of capitation patients.

Implementation tips

Start by identifying the most common social needs (e.g., food, housing, income insecurity) and for each need work to map out an end-to-end process from identification to resolution. Practice coaches can be resources in this process of mapping, which can include the following:

  • Selection of screening tool.
  • Capture of data within the tool (e.g., Z codes for social needs for future tracking and reporting).
  • Development of a referral pathway, including responsible individuals and agencies).
  • Defining success and resolution.
  • Ongoing periodic follow-up.

Seek input from patients, families, clinic staff and referral entities as you develop your process.


  1. Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current psychiatry reports, 20(11), 95. 
  2. Ruiz Escobar E, Pathak S, Blanchard CM. Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review. Preventing Chronic Disease. 2021 Aug 12;18. 
  3. Chavez, L. J., Tyson, D. P., Davenport, M. A., Kelleher, K. J., & Chisolm, D. J. (2023). Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care. Academic pediatrics, S1876-2859(23)00095-5. Advance online publication. 
  4. Ruiz Escobar E, Pathak S, Blanchard CM. Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review. Preventing Chronic Disease. 2021 Aug 12;18. 
  5. Califf, R. M., Wong, C., Doraiswamy, P. M., Hong, D. S., Miller, D. P., Mega, J. L., & Baseline Study Group (2022). Importance of Social Determinants in Screening for Depression. Journal of general internal medicine, 37(11), 2736–2743. 
  6. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatric services (Washington, DC) 2012;63(10):963–73. 10.1176/ 
  7. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 2, Social Determinants of Health and Health Equity. Available from: 
  8. Butler, AB ED, Morgan, MD, MSc, MSHP AU, Kangovi, MD, MS S. Screening for Unmet Social Needs: Patient Engagement or Alienation? NEJM Catalyst [Internet]. 2020 Jul 20; Available from:  
  9. Kaiser Permanente Research Affiliates Evidence-based Practice Center. Screening and Interventions for Social Risk Factors: A Technical Brief to Support the U.S. Preventive Services Task Force [Internet]. 2021. Available from: 
  10. Rojas L, Project S. Accountable Health Communities (AHC) Model Evaluation Second Evaluation Report RTI Point of Contact [Internet]. 2023 [cited 2024 Jan 16]. Available from: 
  11. Sınger A, Coleman K, Mahmud A, Holden E, Stefanik-Guizlo K. Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers. The Permanente Journal. 2023 Dec 15;27(4):136–42. 
  12. Byhoff E, Gottlieb LM. When There Is Value in Asking: An Argument for Social Risk Screening in Clinical Practice. Ann Intern Med. 2022;175(8):1181-1182. doi:10.7326/M22-0147 
  13. American College of Physicians. Closing-the-Loop. Baltimore: Transforming Clinical Practice Initiative--CMS; 2015.