Implementation of social needs screening and intervention in primary care: A systematic review of program-level determinants

Background: Health care systems are investing significant resources in social needs screening and intervention programs. 

Purpose: To understand characteristics contributing to implementation of social needs screening and intervention programs in primary care. Data Sources: CINAHL, Cochrane, Ovid, PubMed, and Scopus (January 2015 to April 2025). 

Study Selection: U.S.-based programs using structured tools to screen adult patients for at least 1 Healthcare Effectiveness Data and Information Set measure (food insecurity, transportation, and housing insecurity) and addressing social needs in primary care settings. 

Data Extraction: Program characteristics; screening and intervention implementation processes; and patient screening, intervention, clinical, and health care use outcomes. 

Data Synthesis: The review included 23 studies. Seventeen reported on screening outcomes, 11 in populations characterized by a particular condition or health care use and 6 in the general population. Programs with the highest percentage of patients screened focused on fewer than 500 patients with a particular condition or health care use and received support from additional staff or volunteers (4 of 17 studies). Of patients screened, 10.1% to 100% reported a social need. Eleven studies reported on receipt of assistance or resources, with a higher percentage of patients receiving assistance or resources among programs that targeted a smaller population. Few studies reported clinical and health care use outcomes, with mixed findings. 

Limitations: Few studies had complete reporting of screening and intervention rates and outcomes. Program characteristics and other screening and intervention processes varied across and within studies. 

Conclusion: Social needs programs focused on smaller, targeted populations were more likely to screen and assist a higher percentage of patients. Programs with adequate staffing may also screen a higher proportion of patients. However, evidence is mixed, particularly for clinical and health care use outcomes. Considerable differences among screening and intervention programs preclude simple suggestions for universal implementation.