Data Storyteller

Is your health center currently in the process of considering, implementing, or revamping a social needs screening program within your EHR or health IT system? This learning collaborative taught participants about health center promising practices and key considerations to support the successful collection, monitoring, and addressing of social needs data. During the series, participants explored the levels of maturity in the social needs screening implementation process.

The levels of maturity included: 

• Level 1: Coming to Consensus
• Level 2: Implementing a Social Needs Screening Tool
• Level 3: Responding to Positive Screens
• Level 4: Monitoring and Using Data

Participants gained information on concrete strategies and IT solutions that have helped to improve internal systems, such as EHR utilization and care team workflows, and increase their capacity to advance individual and population-level health. The HITEQ Center partnered with the Louisiana Primary Care Association to design this series. Louisiana-based health centers were showcased throughout the series to share their experiences with social needs screening, including successes, challenges, and lessons learned.

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.

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

Establishing a social need screening program requires buy-in from both leadership and staff. This resource shares examples of strategies gleaned from interviews with health centers.