Chronic Conditions - Key Activity 17


Use Social Needs Screening to Inform Patient Treatment Plans


This key activity involves all seven elements of person-centered population-based care: chronic disease management; behavioral health integration; 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 well-being, such as housing, food, water, air, sanitation and social support. For individuals with chronic diseases, addressing social health needs can contribute to better management and control of their conditions.[1]

Evidence continues to accumulate that demonstrates not only the ways in which social needs impact physical and mental health outcomes,[2][3][4] but also how worsening physical and mental health conditions can impact social stability.[5][6]

Food and income insecurities are contributing factors to many chronic conditions.[7] Assisting patients with good food choices and sources can contribute to their well-being.

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. This is 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 community-wide health-related social needs and structural determinants. At the individual level, this means acknowledging and beginning to address health-related social needs.[8]

Social needs screening often asks questions about private and potentially stigmatized aspects of a patient’s life (e.g., poverty, interpartner violence).[9] See below in the action steps 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 has experienced homelessness in the past). Have a plan to support staff needs.

Note 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.[10] For example, findings from the recent Centers for Medicare & Medicaid Services’ (CMS’) Accountable Health Communities Model indicate that social needs screening and navigation services reduced emergency department utilization and may have reduced expenditures; however, they did not appear to increase patients’ connection to community services or resolve patients’ social needs.[11] Other possible ways social needs screening can support attending to social needs include strengthening the patient/provider relationship,[12] destigmatizing social services, tailoring care and, at a population level, increasing social investment.[13]

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 outreach and engagement technologies. Practices will need to determine a process to ensure that externally generated screening information is incorporated into the patient record and used for care delivery, risk assessment and management, and management of relevant referrals. Social health information exchanges exist in some communities to identify where patients are getting social services and to 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. Kaiser Permanente, in partnership with the Social Interventions Research and Evaluation Network, conducted a review of social needs screening tools and provides a comparison tool 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 MCPs 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 IT 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 Determinants of Health 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 and community health workers.

Through CalAIM, the DHCS has taken steps to ensure that Medi-Cal patients have access to social support that can impact health outcomes. Connect with your 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 clinicians to meet the needs of their patients. For Medi-Cal patients with the highest level of social needs, MCPs offer ECM (see Key Activity 21: Provide Care Management) and some or all of 14 Community Supports. These Community Supports provide resources to address social needs, such as housing navigation, recuperative care posthospitalization and medically tailored meals. 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 provider.

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 clinicians who connect individuals to social services. Health plans may contract with an online clinician 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 clinician is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination; they lead to higher levels of patient and provider satisfaction.[14]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent/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
  • 211, 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.

Technologies that facilitate community referrals – such as (Aunt Bertha), Purple Binder’s Transforming How People find Community Services and Unite Us’ cross-sector collaboration software – can also help to facilitate community referrals.

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 application of Key Activity 4: Use a Systematic Approach to Decrease Inequities Within your Population of Focus. Case studies provided in the resources linked below provide examples of improvement initiatives.


3. Establish a workflow for screening and referrals.

Suggested team member(s) responsible: QI Lead, multidisciplinary workgroup.

Consider screening before the patient meets with the PCP and have a workflow in place for following up a 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 PCP is aware and can address any positive screen during the visits.

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

Following screening, ask patients for their prioritized need and whether they would like assistance before making a referral.

Provide staff a written script and accompanying signage to build confidence in dealing with the challenging circumstances 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 food insecurity, that could influence details around dietary advice given for conditions like heart disease or weight management. Use trauma-informed ways of engaging patients in their own care, including developing shared goals, providing self-management support and using communication techniques such as motivational interviewing. See more about 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 at the next visit on issues discussed) will help to build trust and support connection to community referrals when the patient is ready.


Examples of how this activity has been implemented

Rogue Community Health in Medford, Oregon, recognized the need to implement screening for health-related social needs. It also recognized that the lack of interoperability in their health information flow was a barrier to collaboration in their community. As a result, it 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. It resulted in a shared community database where patients could be screened at multiple data entry points and where 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.[15]

Implementation tips

Start by identifying the most common social needs (e.g., food, housing, secure income) 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:

  • Selection of a screening tool.
  • Capture of data within the tool (e.g., Z codes for health-related social needs for future tracking and reporting).
  • Development of a referral pathway (including individuals responsible, agencies).
  • Definition of success and resolution.
  • Ongoing periodic follow-up.
  • Seek input from patients, families, clinic staff and referral entities as you develop your process.

Evidence base for this activity

  • Califf RM, Wong C, Doraiswamy PM, Hong DS, Miller DP, Mega JL. Importance of Social Determinants in Screening for Depression. Journal of General Internal Medicine. 2021 Aug 17;
  • Chavez LJ, Tyson DP, Davenport MA, Kelleher KJ, Chisolm DJ. Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care. Academic Pediatrics. 2023 Sep 1;23(7):1411–6.


  1. Equitably addressing social determinants of health and chronic diseases [Internet]. Centers for Disease Control and Prevention; 2022 [cited 2024 Jan 12]. Available from:  
  2. 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. 
  3. 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. 
  4. 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. 
  5. 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. 
  6. 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. 
  7. Food insecurity [Internet]. [cited 2024 Jan 12]. Available from:  
  8. 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: 
  9. 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: 
  10. 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: 
  11. 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: 
  12. 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. 
  13. 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 
  14. American College of Physicians. Closing-the-Loop. Baltimore: Transforming Clinical Practice Initiative--CMS; 2015. 
  15. What We’re Learning About Delivering Whole-Person Care [Internet]. 2020. Available from: