Applying Evidence to Address Social Needs in Health Care: Insights from Complex Care Experts

Blog
Megan Lisch, Center for Health Care Strategies
A group of presenters speaks to an audience.

Factors outside the health care system — housing and food insecurity, lack of employment and transportation, and social isolation — significantly impact people’s health. Recognizing this, health care entities and policymakers are investing in interventions to address patients’ social needs. What does the evidence say about the effectiveness of these programs? How can research inform policy and decision-making?

To explore these questions, last fall, the Better Care Playbook, in partnership with the Camden Coalition and UPMC Health Plan, co-hosted a symposium, Social Needs in Healthcare: Turning Evidence into Practice, ahead of the 2024 “Putting Care at the Center” conference in Pittsburgh, PA. The symposium featured panels of national complex care experts, including clinical leaders, policymakers, researchers, and people with lived experience. Speakers discussed what they are observing in their communities, highlighted research on the most effective strategies for addressing social needs in health care and shared how they translate evidence into practice at the local, state, and national levels. Following are key themes from the symposium session:

1. Evidence measuring the impacts of social needs interventions exists in many forms.

Social care programs in health care are still relatively new. While there is limited peer-reviewed research from randomized control trials and observational studies on social needs interventions and policies, there is a growing body of qualitative and practice-based evidence to inform implementation of these programs. While not as rigorous as other research, these forms of evidence can shed light on how interventions work in different settings and communities. 

This experienced-based approach may also help organizations build the business case to support funding and effective implementation. As noted by Lucy Savitz, University of Pittsburgh School of Public Health and UPMC Center for High-Value Health Care, “You can get evidence from others who are doing similar work, reports in the peer-reviewed literature, leveraging relationships, and being part of learning networks where there’s room at the table for everybody.”

The Better Care Playbook and the Social Intervention Research and Evaluation Network’s (SIREN) Evidence and Resource Library are two online resources that summarize evidence-based and practice-based research for various stakeholder groups. A few examples of sources on social needs interventions include a Playbook collection on housing and health and a review of evidence on social needs screening.

2. It is important to understand how social care interventions work.

Many health care organizations are launching social risk screening and navigation programs, assuming these programs connect patients with social services and improve health outcomes. However, evidence reveals a more complex picture.

In many care settings, patients complete social needs screenings or assessments during provider encounters. SIREN researchers at the University of California, San Francisco, suggest various pathways to better health that go beyond the assumption that social care screenings lead to referrals to address unmet social needs.  These include feeling emotionally supported by navigators and community health workers, improving connections with clinical health care services, and using social needs data to tailor care plans and decisions. “These alternative pathways are likely contributing to the positive outcomes that we’re seeing from many of these social care programs,” said Caroline Fichtenberg, co-director of SIREN.

Trust-building and effective communication are key success factors for social needs screening and assessment in clinical settings. Lack of meaningful connections with providers, and an unclear understanding of how social risk information will be used may limit the impact of screenings and subsequent referrals. Patients may not be interested in sharing sensitive information during a visit if they are unaware of how it is used. Camden Coalition National Consumer Scholar Pamela Corcoran shared her experiences as a patient and family caregiver on how she invites her care team to get to know her as an individual: “I am not my diagnosis and I am not just a billing code. Those do not address who we [patients] are and what we need.”

3. Sustainable funding and community partnerships are crucial to support new and ongoing work.

Financing is a critical component of any intervention to address social needs. “The interventions that seem to work better are ones that put financing together with the approach, that way you can deliver an effective package of interventions to people,” said Seth Berkowitz, a researcher at the University of North Carolina, Chapel Hill. Various payment models exist for these programs, but each has its limitations. For example: fee-for-service payments may provide predictable revenue but be over or underused based on the program’s arrangement; capitation rates offer providers greater flexibility but may not cover the true cost of services; and value-based payments promote accountability but may not be tied to measures that reflect the intervention’s true impact.

It is also important to consider how health care systems and community-based organizations (CBOs) can partner to deliver social needs interventions, what role each plays, and financing implications. Health systems may enhance clinical outcomes, while CBOs can focus on prevention and resource security. These partnerships vary and can be costly, as funds are needed to build CBO capacity and modify clinical workflows. A few tools that may help address funding questions include an ROI Calculator for Partnerships to Address the Social Determinants of Health, a supplemental guide to evidence for health-related social needs interventions, and a guide to contracting with CBOs.

4. Measuring impact requires data collection to address community priorities.

Given the limited evidence on social needs interventions, there is a push from organizations funding this work for measurement and accountability to assess the impact of these programs. Identifying the right metrics and sources to determine prevalence and need requires significant effort, resulting in numerous data points that must be monitored. “Health systems are wrestling with tens and sometimes hundreds of measures. How does anyone focus on anything within a health system? If everything is a priority measure, then nothing is. Better policies and incentives are needed to focus health systems on what matters to patients and communities,” shared Chethan Bachireddy of Harris Health.

It is easy to lose patient experiences in complex data systems and be overwhelmed by the volume of data collected across systems. If existing quality standards do not prioritize patient experiences, what changes can be made? How can organizations successfully measure what their communities ask about, such as meaningful engagement? During planning activities, it is important to understand what communities truly value. Bachireddy added, “It starts with honoring people’s voices and lived experiences, so when we look at success, we [measure it through] the experience of a patient.”

5. Engaging community members to meaningfully inform social needs interventions is critical.

Health care organizations engage community stakeholders in many ways to inform social care programs, including as board members and through formal or informal partnerships. Session speakers recognized that for some organizations, however, partnerships may be top-down or lopsided rather than supporting meaningful relationships and engagement. “We are often asking one person to represent the perspectives of an entire community. We need to move toward a model that creates different entry points for people to both participate and develop as leaders who can have power to make decisions,” said Damon Francis of Alameda Health System.

Collaborating with communities and people with lived experience provides opportunities to co-design social care interventions that address the priorities of those receiving services and supports. To prepare for engagement, it is important to recognize where community and system partners fit into the system to identify potential privilege and power dynamics that may hinder meaningful collaboration.

6. Policy levers at the federal, state, and local levels can support social needs interventions.

Initiatives to address health-related social needs are being prioritized within Medicare and Medicaid, as well as at a local level. In 2024, Medicare began coverage of new services to address social needs including a social determinants of health risk assessment, Community Health Integration services that may be delivered by community health workers, and Principal Illness Navigation services. Additionally, Medicare Advantage plans have opportunities to offer supplemental benefits that may be tailored to address social needs. One resource shared to support plans in understanding the evidence for some of these benefits is a new Medicare Advantage Supplemental Benefits Database, which includes interventions such as transportation for non-medical needs, food and produce, and structural home modifications.

At the state level, a growing number of Medicaid agencies have approved or pending Section 1115 demonstration waivers to use funds to address health-related social needs. In January 2024, Pennsylvania submitted a 1115 waiver application to focus on housing, food security, and community reentry with support from managed care organizations and trusted CBOs. Erin Dalton of Allegheny County Department of Human Services described opportunities available at the county level to integrate data across systems to better identify and address individual needs. In Allegheny County, initial and ongoing investments have supported one of the country’s best integrated health and human services data systems. This system hosts publicly available data sets and allows community members and providers to view health records.

Share Your Insights and Successes

Do you have emerging evidence or interventions related to addressing social needs in health care? Share your insights on nutrition, housing, employment, transportation, and social isolation with the Playbook. We are interested in growing our library of evidence and implementation best practices to help those in the field strengthen and build successful programs.


The Camden Coalition is accepting proposals for Putting Care at the Center 2025, taking place October 15-17 in Portland, OR. For more information, visit https://camdenhealth.org/annual-conference/.