Complex construction: A framework for building clinical-community partnerships to address social determinants of health

A growing number of health care providers in New York are screening for social determinants and forging partnerships with social service organizations to address economic and social factors that affect health, such as substandard housing, food insecurity, and poverty. However, successfully screening patients for social needs, referring them to organizations that can provide needed services, and following up to determine outcomes, is all extremely complex.

United Hospital Fund has prepared a framework designed to help primary care providers screen their patients for social determinants of health and partner with community-based organizations (CBOs) that can respond to those needs. The framework provides guidance on selecting a screening tool, developing a realistic workflow, identifying appropriate CBO partners, and building and maintaining those new relationships. The accompanying report explores how the processes can be developed and describes the challenges to achieving scale and sustaining these efforts.