According to the American Hospital Association (AHA), “80 percent of health outcomes are shaped by the social determinants of health – the conditions in which people are born, grow, work, live and age. These factors include safe and stable housing, access to food and transportation, social connection, safety, and environmental exposures.”

 leveraging technology to facilitate social needs screening and referrals

It is imperative when caring for a patient, that their social needs are evaluated. When social needs screening takes place and gaps are found, they can then be referred to the appropriate resources.

What are Social Needs?

Social needs are factors that contribute to the patient’s health and well-being, outside the walls of a medical facility.

Three key social needs to screen for include but are not limited to the following:

  • Transportation
  • Food
  • Housing

Social determinants of health (SDoH) are the economic and social conditions that affect an individual's overall quality of life and health. These include:

  • Economic stability
  • Education
  • Healthcare
  • Environment

When a patient’s SDoH is not met, their social needs are often also compromised.

1 Transportation

Some patients find it difficult to get a ride to their medical appointments. They experience anxiety over how they will even arrive at the medical facility, let alone what their experience will be once they get there. A patient that has experienced strain in finding transportation to an appointment, is not going to be as receptive when receiving medical attention. Screening for a lack of transportation can allow for the patient to be put in contact with the appropriate resources, like a rideshare system.

2 Food

Diet is often a topic of discussion when a patient is being treated. What they can and can not eat is set out, usually in a strict list format. Sadly, what is not usually discussed, is their means of getting the food. A patient can know they should not eat unhealthy food, but if they do not have access to a nutritious diet, they are not going to succeed. Ensuring the patient has access to healthy food can mean making them aware of food pantries in their area, and those pantries are well stocked with the food they need.

3 Housing

Maslow’s hierarchy of needs states that one cannot complete simple tasks if physiological needs are not being met. A place to stay is one of the most basic needs, and making sure it is safe and secure is almost just as important.

When taking a holistic and all-encompassing approach to a patient’s health, it is important to first take a look at their living environment. Is it a safe, clean, and healthy place to live? If a patient is not living in a place like this, their medical community must be made aware, and resources can be provided.

The Social Needs Screening and Referral Process

Screening for social needs can be facilitated in a few different ways. It can be done by:

  • Medical care providers
  • Non-clinical staff members
  • Self-assessment survey filled out by patients

There are four important steps in the social needs screening and referral process that can be done through any of the modes listed above.

  • Patient identification: Whether every patient is put through a screening process or the patient is identified as high risk or having their needs not met, this must be determined ahead of time.
  • Assessment: A care team, medical provider, or a survey provided to the patient will help document important questions asked to the patient, to determine if their social needs are being met.
  • Referral: Taking the information provided in the screening process and putting it into action is vital. Technology has made it easier than ever to connect patients with the resources they need, whether it be a ride share service, a food pantry, or affordable housing.
  • Closing the loop: It’s important to set aside time for routine follow-ups to ensure the patient’s needs are continuously being met. It’s also important to track the communication among all stakeholders, and those invested in the patient’s life. This will include a care team, their PCP, and other providers.

Common Screening Challenges

Several obstacles often prevent patients from being screened for social needs. This can involve difficulty on the clinician’s part of the patients. Interpersonal communication, especially in a medical setting can be complicated, this is why leveraging technology to facilitate social needs screening and referrals can be useful.

1Clinician screening blocks

Clinicians may sometimes find it difficult to screen patients for social need gaps.

2The trouble with bedside manner

There may be some discomfort in initiating conversations around potentially sensitive subjects, like social needs. It could be a fear that patients will perceive the questions as presumptuous or offensive if not brought up gently and empathetically.

3Insufficient time

Providers are already only given a limited amount of time to speak with the patient about their medical needs. It can be difficult to also set aside time to build enough of a repertoire with the patient, for them to feel comfortable in speaking on such a sensitive topic.

4Documentation and social needs tracking systems are lacking

The screening process is all about collecting the appropriate data. Some clinicians may not have a standardized process for documenting social needs or tracking referrals. If it occurs to them that their patient’s social needs are not being met, do they have a system in place to document this?

5Perceived lack of efficiency

According to the AHA, “a Robert Wood Johnson Foundation survey observed that four out of five physicians are not confident with their ability to meet the patients’ social needs and approximately half of physicians feel ill-informed about the resources available.”

Patient Screening Blocks

There are numerous reasons an individual may be hesitant to share their social needs are not being met, including:


A patient may feel shame and embarrassment towards sharing that they are not able to provide certain social needs for themselves. This can result in defensiveness towards questioning.


Patients may feel fear of what the provider will do with the sensitive information they share; they fear having their children taken away, being taken from their own home, or simply being treated differently.


A patient may be reluctant to allow others to view them differently or as incapable of having their needs met. They may even worry this will result in less medical attention.


Patients that have experienced trauma may not yet be ready to accept their life is difficult. This is why technology-based surveys, asking very straightforward and factual questions can be helpful.

How can Referrals Help?

Social needs screening must be implemented into direct action, by providing easy-to-access resources. It is important to have an arsenal of social resources ready for when the occasion arises. This can mean partnering with organizations ahead of time, such as rideshare services and food pantries, and knowing the cost/benefit that this will afford the patient.

By referrals to resources being offered, the patient is better empowered to manage their life and their health.

The importance of senior care coordination leveraging better access to care delivery methods

Leveraging Technology to Facilitate Community Screening and Referrals

Rainbow Health's leading solution facilitates social needs assessments and enables users to search for essential social services, track referrals, and coordinate those referrals in real-time to ensure coordinated care and address SDoH. Our solutions help health plans, hospitals, health systems, and government organizations connect communities to resources for a better life.

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Author's Bio

Ayushi Patel Mobisoft Infotech

Ayushi Patel

Ayushi Patel is the Director of Strategy & Innovation at Mobisoft Infotech. She leads the strategic partnerships and initiatives in the healthcare division. Her experience includes healthcare administration, business development and sales, and customer success management.