Pregnant People - Key Activity 7


Use Social Needs Screening to Inform Patient Treatment Plans


This key activity involves the following elements of person-centered population-based care: 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 and well-being, such as housing, food, water, clean air, sanitation and social support.

Evidence continues to accumulate that demonstrates the ways in which social needs impact physical and mental health outcomes. This is particularly true for pregnant and postpartum individuals and their families. The relationship is not unidirectional. Worsening physical and mental health conditions have also been shown to impact social stability.[1]

Health-related social needs and unmet social needs are known to be related to a variety of perinatal outcomes: unintended pregnancy, preterm birth and maternal mortality. Your practice must recognize that a patient’s pregnancy and postpartum care decision-making is shaped by larger systems and life circumstances. Screening for and addressing social needs will help your practice better understand the populations you serve and improve their birth outcomes.[2]

Discrimination related to race and ethnicity, immigrant status, sexual orientation and/or occupational status has repeatedly been associated with negative mental and physical health outcomes.[3] Providing healthcare in the absence of attending to the life circumstances in which patients and their families are living risks doing harm rather than providing assistance or support.

Here are some places to start to integrate equity and social needs work:

  • Identify and agree to use a specific social needs screening tool. Test this tool and develop processes to use it consistently.
  • Hire and train behavioral health staff who are skilled at discussing and incorporating the impacts of racism on individual mental and physical health.
  • Social needs screening often asks questions about private and potentially stigmatized aspects of a patient’s life (e.g., poverty and inter-partner violence).[4] Ensure staff are trained to screen for and respond to social needs in a trauma-informed way (See the Resource: Trauma-Informed Population Health Management)
  • Integrate demographic data with chronic disease and social needs data. Too often such data is siloed in the EHR and requires staff and organizations to intentionally consider opportunities to integrate and report out such data.

Social needs screening is an opportunity to both make visible the factors outside of the clinic that greatly impact patients’ health and to connect and link patients and their families with appropriate resources to meet those needs. Care teams reflect on screening results to tailor adjustments, such as prescribing or location/timing of visits, to individual care plans. Considering the intertwining of social needs with physical and behavioral health allows care teams to reflect on root causes and can lead to improved individual and collective health outcomes.

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.[5] For example, findings from the recent Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Model indicate that the social needs screening and navigation services reduced ED utilization and may have reduced expenditures but did not appear to increase patient’s connection to community services or resolve the patient’s social needs.[6] Other possible ways social needs screening can support attending to social needs include by strengthening the patient/provider relationship,[7] destigmatizing social services, tailoring care and, at a population level, increasing social investment.[8]

Technology-enabled screening referenced in the technology section can be utilized to screen patients for social needs through the channels described: directly in the EHR, in applications used by care coordinators, and directly to patients via patient-facing outreach and engagement technologies. Examples of screenings include depression/anxiety, substance use disorder, health related social needs and domestic violence, to name a few.

Health centers will need to determine a strategy to ensure that externally generated screening information be incorporated into the patient record, recognizing its impact on care delivery for pregnant people, 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. Kaiser Permanente, in partnership with the Social Interventions Research and Evaluation Network (SIREN), conducted a systematic 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:

For the perinatal population, it is especially important to assess the safety of the pregnant person from intimate partner violence and determine if any intervention or support is needed. Consider a validated tool that has comparable questions found in the California Comprehensive Perinatal Services Program (CPSP) intake assessment.

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 who 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, Department of Health Care Services (DHCS) provides a list of 25 Priority Social Determinants 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. Train providers to add these codes to the pregnant patient’s problem list as appropriate.

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 Healthcare Services (DHCS) has taken steps to ensure that Medi-Cal members have access to social support that can impact health outcomes. Connect with your managed care plan (s) (MCPs) and regional area consortia (RAC) 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 members. For Medi-Cal members with the highest level of social needs, MCPs offer Enhanced Care Management (see section on care management) and some or all of 14 Community Supports: these Community Supports provide resources to address social needs such as housing navigation, post-hospitalization recuperative care, and medically tailored meals. Some MCPs use the new CalAssist tool for Medi-Cal members 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.

Beyond these relatively new benefits that may meet the social needs of your pregnant and postpartum patients, your practice may also refer to existing community-based organizations and public agencies to support patient needs like nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Existing free social support programs for your pregnant and postpartum patients include California Home Visiting Programs and home visitors (public health nurses or peers) who are well-versed in meeting patient social needs. Such existing programs, often administered by your local public health department in partnership with community-based organizations, should be leveraged where possible to support new social needs screening and response processes in your practice.

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 who 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.[9]

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
  • 2-1-1 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 Key Activity 4: Use a Systematic Approach to Decrease Inequities within the Population of Focus. 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 PCP is aware and can address any positive screen during the visits.

Train staff in the new workflows and Implementing Population Health Management in Trauma-Informed Ways. Staff often initially resist screening if there is a sense they feel they don’t 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.
  • Providing a written script for staff and accompanying sage can build confidence in dealing with the challenging circumstances many patients experience.


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

Suggested team members 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 pregnancy. If a patient screens positive for transportation insecurity, discuss what options might be available to ensure proper access to appointments. 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 here: Implementing Population Health Management in Trauma-Informed Ways

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. By 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 issues discussed at the next visit, will help to build trust and support connection to community referrals when the patient is ready.

Example 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

  • Following screening, ask patients for their prioritized need and whether they would like assistance before making a referral.
  • Health-related social needs such as food, housing, and income insecurity can contribute to unhealthy behaviors and lifestyles that contribute to the development or worsening of disease processes during pregnancy. For example, lack of access to nutritious foods may impact a pregnant patient’s ability to manage their gestational diabetes. It is important to screen pregnant people for those social needs, as it may be challenging to deal with their conditions until their social needs are resolved.
  • Food and income insecurities are contributing factors to many chronic conditions. Assisting patients with good food choices and sources can contribute to their well-being. The stigma of using community resources for food insecurity can be a barrier to some. Providing a goodie bag of food and connecting the patient to the local food support (see Medi-Cal program supports) can help overcome the stigma while empowering staff.

Examples from the Center for Care Innovation (CCI)

Case studies of how practices implemented screening tools and undertook innovative quality improvement activities to address food insecurity and transportation insecurity.

Addressing Food Insecurity: Concrete Advice From Clinic Leaders

Food Insecurity: Hidden Hunger in Los Angeles

Addressing Transportation Insecurity: Concrete Advice From Clinic Leaders


  2. ACOG. Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care [Internet]. 2018. Available from: 
  3. Alegría M, NeMoyer A, Falgàs Bagué I, Wang Y, Alvarez K. Social Determinants of Mental Health: Where We Are and Where We Need to Go. Curr Psychiatry Rep. 2018 Sep 17;20(11):95. doi: 10.1007/s11920-018-0969-9. PMID: 30221308; PMCID: PMC6181118. 
  5. 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: 
  6. 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: 
  7. 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. 
  8. 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 
  9. Dassau E, Atlas E, Phillip M. Closing the loop. International Journal of Clinical Practice. 2011 Feb;65:20–5. Available at https://www.cms.gove/priorities/innovation/files/x/tcpi-san-pp-loop.pdf