Preventive Care - Key Activity 14


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 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] Social barriers also have a significant impact on patients’ ability to carry out preventive health measures, such as recommended breast, colon and cervical cancer screenings. Common barriers include financial insecurity, housing insecurity, transportation, language, health literacy, behavioral health needs, cultural beliefs, parenting responsibilities and fear of test results; each affect a patient’s ability to prioritize and carry out recommendations for screening. Unless these barriers are understood and addressed, patients will not be able to carry out the testing.[6]

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 and 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, interpartner violence).[8] See below about how to screen for and respond 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 Centers for Medicare and Medicaid Services (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 patient’s connection to community services or resolve the patient’s 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 increasing social investment at a population level.[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 outreach and engagement technologies. Practices will need to determine a process to assure that externally generated screening information is 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 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, 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 members have access to social support that can impact health outcomes. Connect with your managed care plans (MCPs) and regional area consortia to understand what services and resources they have in place to support patients’ 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 17: Provide Care Management) and MCPs offer some or all of 14 CalAIM Community Supports: these community supports provide resources to address social needs, such as housing navigation, recuperative care post hospitalization, 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.

Many patients who screen positive for social needs 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 leads to higher levels of patient and provider satisfaction.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, 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 (see Key Activity 4. Use a Systematic Approach to Address Inequities within the Population of Focus). Case studies provided in the resources linked below provide examples of these improvement initiatives.

3. 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, discuss the transportation needs as part of the broader discussion of cancer screening options. 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 the 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. 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.

4. 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 on a positive screen (e.g., meet with the 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 screens 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 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 many patients experience.

See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

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


  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. Ponce-Chazarri L, Ponce-Blandón JA, Immordino P, Giordano A, Morales F. Barriers to Breast Cancer-Screening Adherence in Vulnerable Populations. Cancers. 2023 Jan 18;15(3):604. 
  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 . Transforming Clinical Practice Initiative SAN Power Packs: Closing the Loop [Internet]. Centers for Medicare & Medicaid Services; 2019. Available from: