Social needs screening and referral program at a large US public hospital system, 2017

Many health care providers and systems are developing and implementing processes to screen patients for social determinants of health and to refer patients to appropriate nonclinical and community-based resources. The largest public health care system in the United States, New York City Health + Hospitals, piloted such a program in 2017. A qualitative evaluation yielded insights into the implementation and feasibility of such screening and referral programs in health care systems serving low-income, minority, immigrant, and underserved populations.

It is widely recognized that social determinants of health (SDOH), or the conditions in which people are born, grow, live, work, and age, affect health and well-being. A subset of social needs, including housing, food, and safety, are associated with health care utilization and health outcomes, particularly among low-income populations. The push toward value-based care in the United States at both state and federal levels has sparked a growing impetus among physician groups and hospital systems to identify these needs in the clinical setting and refer patients to appropriate social services.