Screening for Social Needs

Publication Year: 2018
Patient Need Addressed: Behavioral health, Financial insecurity, Food insecurity, Homelessness/housing, Patient satisfaction/engagement, Trauma
Intervention Type: Best practices
Type of Literature: Grey

It is increasingly recognized that social determinants of health—factors such as socioeconomic status, education, housing stability, nutrition and access to healthcare—have a greater impact on the health of individuals than genetic predispositions or medical care. Researchers attribute 70 to 80 % of health outcomes to social, behavioral and environmental factors. Addressing social determinants, thus, is essential to improving health, reducing health disparities and decreasing costs. As states grapple with expanded Medicaid coverage, they are introducing new payment models that hold providers financially accountable for quality outcomes. These payment models provide new incentives for providers to screen for and address unmet social needs—and many Medicaid programs are requiring that they do so. According to a recent survey by Kaiser Family Foundation, in 2017, 19 states required Medicaid plans to screen for and/or provide referrals for social needs.

This brief aims to provide consumer health advocates with an overview of social needs screening tools, so they can better advocate for the effective and culturally competent use of these tools in state public programs.

Insights Results

Overview of article

  • This is a brief to provider consumer health advocates with an overview of social needs screening tools


    Choosing a Screening Tool
  • 1) Determine needs of population. Commonly recommended domains for screening tools are: housing and food insecurity, education/literacy, employment/income, intimate partner violence, and social connection. Behavioral domains for assessment include: alcohol use, tobacco use, physical activity, and depression. The Institute of Medicine (IOM) recommends health systems screen on a minimum of 10 social and behavioral domains and one neighborhood/community domain
  • The most popular screening tools include: Accountable Health Communities Tool (CMS), Health Leads, IHELLP (Medical Legal Partnership), PRAPARE (National Association of Community Health Centers), Your Current Life Situation (Kaiser Permanente). All tools have less than 20 questions and assess a combination of the domains noted above
  • Social needs screening best practices: 1) Patient centered and involves family decision making; 2) Conduct within a comprehensive process and system that supports early detection, referral, and linkage to a wide array of community-based services; 3) Engages the entire practice population rather than targeted subgroups; and 4) Acknowledges and builds upon strengths of patients, families, and communities
  • CMS and the National Quality Forum (NQF) recommend using EHRs to collect and manage data from screenings
    Examples of Screening
  • TennCare screens participants for unmet needs in housing, social support, food security, and employment. Managed care organizations (MCOs) develop customized needs assessments to inform care management and coordination as well as program evaluation. MCOs must report housing and employment data to the state
  • Michigan’s Pathways to better Health Program involves community health workers visiting the homes of participants and using a tablet-based checklist to screen for unmet employment, education, housing, and food security needs. The data is entered into a web-accessible portal and used to develop care coordination strategies

Key takeaways/implications

  • Screening should be accompanied by a strong referral system so patients can be connected to services they need quickly. Recommend using electronic platforms to catalogue community resources
  • Screening should be accompanied by advocacy for investments in community infrastructure and services through value-based payments and flexible spending arrangements
  • Evaluations are an important form of assessment to ensure screening and referrals are meeting patient needs
  • Ensure that provider organizations invest in training around trust and cultural competency to ensure screening accurately captures patient needs