CIN stories from the field: Social needs screening and referral models

Many health care organizations have begun to assess and address patients’ social needs — such as homelessness, food insecurity, and social isolation — in addition to their medical needs in an effort to improve clinical outcomes and control total cost of care. For this case study series we interviewed four early adopters to identify the operational changes they made to successfully implement and sustain social needs screening and referral programs. The organizations interviewed mirrored the make-up of CIN members and included a large integrated health system, a Federally Qualified Health Center, a health plan, and an independent practice association. This diverse group of organizations identified lessons related to standardizing social needs screening and referral programs. A few of the common lessons learned are highlighted below.