Scaling Primary Care Social Needs Screening and Referrals in New York City’s Safety-Net Health System

Alessandra Calvo-Friedman
Jenifer Clapp
Samantha Lily Kumar
Ayrenne Adams
Kriti Gogia
Nichola J. Davis
Case Example
June 2023
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An overview of NYC Health + Hospital’s implementation of a primary care-based social needs screening and referral program, including key implementation challenges and success factors.


Stakeholders across the health care system are increasingly recognizing the importance of social needs screening as a tool for linking patients with resources to address health-related social needs. However, implementing social needs screenings in clinical settings presents various challenges for providers and staff. Of particular concern is effectively managing administrative burden and ensuring sufficient resources to address identified social needs. In 2017, NYC Health + Hospitals (NYC H+H), New York City’s safety-net health care system, began implementing a social needs screening and referral program within primary care clinics located across the system’s 11 hospital ambulatory sites and approximately 30 community health centers.


The case study outlines the development of new clinical workflows and key resources to support implementation of NYC H+H’s social needs screening and referral program. It also includes practical tools used to standardize screening protocols, including the social needs screening form, a staff workflow guide, and a screenshot of the program's quality measure dashboard.

The authors describe changes recommended by an internal stakeholder group to the program's screening workflow and tools following an initial pilot in a small number of clinics. Recommended changes focused on minimizing staff burden, integrating the screening within existing workflows, providing patients with accessible resource connections, and using metrics to encourage quality improvement. Following full implementation, rates of patients screening positive for at least one need varied widely across clinic sites. Higher rates were observed in clinics that adopted predetermined workflows for screening and follow-up, allowed patients to self-complete screening questions (often using tablets), and engaged in more thorough staff training.


NYC H+H developed a social needs screening and referral program that may be replicated by other health care organizations. NYC H+H engaged in an iterative process, drawing upon lessons learned from a pilot intervention and insights from multiple internal stakeholder groups. Stakeholders interested in scaling a standardized social needs screening approach in primary care settings can learn from NYC H+H experience.

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