Scaling primary care social needs screening and referrals in New York City’s Safety-Net health system

Identifying and addressing patients’ social health are essential to addressing health equity. Screening for social needs and connecting patients to resources in clinical settings is one way to identify and address the social factors that contribute to health. Policy makers are increasingly turning to incentivizing and requiring social needs screening and referrals to encourage health systems to identify and address patient social needs. NYC Health + Hospitals implemented and scaled social needs screening and referrals starting in 2017 across primary care clinical sites. The health system’s approach was to focus on screening for patients’ highest-priority needs for which there were available resources, to prioritize effective screening and referrals over universal screening, and to establish referral workflows. Implementing meaningful social needs screening and referrals requires a significant investment in creating screening workflows and in building key resources to meet patient needs.