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Improving social needs intervention research: Key questions for advancing the field

C. Fichtenberg, D. Alley, K. Mistry
Am J Prev Med

Spurred by accumulated evidence documenting how social determinants of health shape health outcomes as well as the push for better value, the healthcare sector is embracing interventions that address patients’ health-related social needs. An increasing number of healthcare organizations and payers are experimenting with strategies to identify needs and connect patients to resources that address identified needs with the goal of improving health outcomes, reducing avoidable utilization of costly health services, and improving health equity. Although many studies link social factors to health, relatively little published research exists about how the healthcare sector can effectively intervene to help identify and address social needs. This paper summarizes emerging evidence and identifies key areas where more research is needed to advance implementation and policy development. Although some healthcare-based social needs interventions have been shown to improve health and reduce avoidable utilization, important gaps remain in terms of comparative effectiveness and cost effectiveness of social needs intervention approaches. Additionally, the field would benefit from an increased understanding of mechanisms of action to maximize practitioners’ ability to tailor interventions. More research is also needed to guard against unintended consequences and ensure these interventions reduce health inequities. Finally, implementation science research should identify supports and incentives for adoption of effective interventions. Focusing both public and private research efforts on these evidence gaps can help advance identification of interventions that maximize both health equity and healthcare value.

Supplement information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Fichtenberg CM, Alley DE, Mistry KB. Improving social needs intervention research: Key questions for advancing the field. Am J Prev Med. 2019;57(6):S47-S54. DOI:

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Publication year
Resource type
Peer Reviewed Research
Social Needs/ SDH
Health & Health Behaviors
Patient Experience of Care
Provider Experience of Care
Social Determinant of Health
Housing Stability
Not Specified
Study design
SIREN Resources