Considerations for identifying social needs in health care systems: A commentary on the role of predictive models in supporting a comprehensive social needs strategy

Social determinants of health such as education, income, social capital, and racism are the upstream “causes of the causes” of health disparities that affect major morbidity and mortality outcomes. Further downstream, in clinical practice, social determinants of health may crystalize as patient social needs, specific nonmedical acute resource needs that lie on the causal pathway between social determinants and disparities in health and health care outcomes. Social needs may include lack of access to transportation, food insecurity, or insufficient funds to pay for housing, medications, or utility bills. Health care systems are increasingly convinced that addressing patient social needs is a promising strategy for achieving the Triple Aim to improve care, population health, and costs. Public and private health care organizations as well as health researchers have been exploring strategies to address patient social needs in health care settings. Most strategies have focused on referring patients to social services and community resources. For such strategies to succeed, these organizations must first systematically identify patients who have social needs. However, clinicians and staff are often unaware of patients experiencing social needs.5 As a result, universal screening of all patients has been proposed, as has targeted outreach to high-risk groups, such as patients with certain diseases or patients incurring high health care costs. Predictive analytics may provide information to plan and target scalable and comprehensive social needs strategies.