Defining success in resolving health-related social needs

The U.S. health care system is increasingly testing programs to address patients’ social needs. Examples include large integrated delivery systems such as Kaiser Permanente and pilots funded through the Centers for Medicare and Medicaid Services (CMS) such as the Accountable Health Community (AHC) model and Comprehensive Primary Care Plus (CPC+) initiative. Within the next year, the number of patients and beneficiaries screened for social needs and referred to community services will jump from thousands to millions.

As we move toward a more person-centered and equitable health care system, the ongoing analysis of these and other related programs will shape our understanding of how such approaches affect the total cost of care, patterns of utilization, and health outcomes. Yet with all this experimentation and innovation, we lack a shared definitional framework of what success looks like in addressing social needs.