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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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Resource Overview

Population Health Management (PHM) is an evolving concept encompassing a suite of emerging technologies to aggregate, analyze and use data to improve clinical and financial outcomes.  PHM tools enable health centers to identify, monitor and target care to patients within a population. Resources in this section provide a conceptual foundation to help health center staff deepen their understanding of PHM and how the social determinants of health can be used to improve outcomes.

PHM and SDH Concepts and Overview Resources

Lessons Learned in Social Need Screening

Lessons Learned in Social Need Screening

Takeaways and examples from interviews with health centers

Download the full Lessons Learned publication in the Documents to Download section below. 

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

In an effort to better address patients’ social needs, health centers are turning to screening tools such as Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE), among others, to collect a wide range of social needs data. This information can be used to inform clinical decision making, develop internal programming, and refer patients to community-based resources. Despite recent momentum in the area of social needs screening, implementation at community health centers continues to be varied and uneven, and many are looking for guidance from peers on how to screen for social needs and respond to positive screens.

HITEQ explored the current landscape of social need screening implementation by first reviewing recent literature and publications. This information was then contextualized in past experiences and conversations with health centers, ultimately building upon our existing knowledge of the drivers, opportunities, and challenges of social needs screening.

To take a deeper dive, HITEQ conducted interviews with eleven health centers in Fall 2021. We specifically reached out to selected health centers that successfully reported across all four categories of social need in the 2020 Uniform Data System (UDS) report, therefore indicating some level of consistent deployment of social need screening. These UDS categories include food insecurity, housing insecurity, financial strain, and lack of transportation or access to public transportation. The health centers interviewed represented different states and localities, as well as different population and catchment sizes.

This resource is designed to support health centers by outlining promising practices that were illuminated in the interviews with health centers who found success implementing their social need screening programs. In particular, the interviews brought to light that to implement an integrated screening program that produces high-quality data, health centers must utilize digital health solutions and leverage their electronic health record (EHR). This resource shares examples of these solutions in practice, and is designed to equip health centers with the information necessary to implement a screening program that limits burden on staff, is meaningful for patients and their care, and advances population health.

The digital solutions presented can be used to help health centers begin conceptualizing their social need screening program, and support health centers with existing programs to identify gaps and opportunities for improvement. How health centers apply the information detailed in this resource will depend on their capacity, resources, workflows, and level of readiness.

Previous Article Strategies for Determining the Frequency of Social Need Screening
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Documents to download


This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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