Effective Strategies to Address Social Need in Communities

Short Summary

Understanding Social Need And Its Importance

A woman and a man are laughing and laughing.
Image by vecstock on Freepik

Embarking on our journey, let’s first delve into the realm of social need and its profound significance in shaping health outcomes. Social needs, an integral part of the World Health Organization’s social determinants of health, can manifest as housing instability, food insecurity, and a lack of affordable childcare, particularly amongst systematically disadvantaged populations. These unmet needs, deeply rooted in the fabric of society, are not just concerns for individuals; they are pivotal challenges that health systems must confront to ensure holistic well-being, as emphasized by the World Health Organization.

Defining Social Need

Distinct from the broader concept of social determinants, social needs specifically refer to the unmet material and essential requirements at an individual level, which are often referred to as basic needs. While the terms have often been used interchangeably, the evolving narrative in healthcare systems now distinguishes social needs as those basic necessities that, when unfulfilled, impede an individual’s ability to maintain good health. Some examples of social needs include:

Addressing these social needs is crucial for improving health outcomes and reducing health disparities.

These encompass a spectrum of factors, from economic stability to neighborhood environments, that collectively shape a person’s quality of life and health outcomes.

The Role of Social Need in Health Systems

Healthcare organizations are increasingly recognizing that addressing patients’ social needs goes hand-in-hand with improving health outcomes and reducing costs. Unmet social needs often translate into frequent emergency department visits and missed healthcare appointments, underscoring the interconnectedness of social factors and health.

By weaving social care into the healthcare fabric, we not only enhance individual well-being but also contribute to the sustainability and efficiency of health systems at large.

Key Areas of Social Need

Team working together on project
Image by freepik on Freepik

Transitioning from the ‘why’ to the ‘what’, we identify the primary arenas where social needs wield the most influence on health: housing instability, food insecurity, interpersonal violence, and employment opportunities. Each area is a critical determinant of health that, when neglected, can have a domino effect on an individual’s life, exacerbating health disparities and hindering community welfare.

Housing Instability

Consider the foundation of stability in life: housing. Safe and secure housing is not merely a shelter but a determinant of health that affects quality of life and long-term health outcomes. Housing instability, which can include living in unsafe neighborhoods or contending with the threat of eviction, contributes to high levels of stress and can precipitate a cascade of health issues. In this context, personal safety plays a crucial role in maintaining overall well-being.

Job instability, a potential catalyst for housing insecurity, further compounds the issue. Innovative initiatives such as Housing First programs demonstrate the positive impact of prioritizing housing stability, showcasing reductions in emergency room visits and hospitalizations.

Food Insecurity

Nourishment extends beyond the physical; it’s a pillar of health and well-being. Food insecurity, the lack of access to sufficient and nutritious food, is a poignant example of an unmet social need with far-reaching consequences for both mental health and poor health. In the context of Maslow’s hierarchy of needs, addressing food insecurity is essential for individuals to progress towards higher levels of personal growth and self-actualization.

Addressing food insecurity is not only about ensuring a full stomach but also about preventing chronic conditions and fostering a healthier population.

Employment Opportunities

Gainful employment is the thread that often ties together the security of housing and food. Stable employment goes beyond financial gains; it is about ensuring a sense of purpose, belonging, and the opportunity to contribute to society. However, when individuals face job instability, it can lead to a precarious cycle of housing insecurity and other social needs that are left unaddressed.

Assessing And Identifying Social Needs

With a clear understanding of the key social needs, our next step is to explore how healthcare systems can assess and identify these needs within patient populations. The process is multi-layered, involving significant screening and the integration of social services within care delivery.

Community Health Assessments

Community health assessments serve as a compass, guiding healthcare organizations to uncover barriers to health and pinpoint patient populations that require the most support. These assessments are not just about collecting data; they are about understanding the resources within a community and ensuring that information is shared securely with community organizations for effective intervention.

Social Risk Scores

Social risk scores are the metrics that quantify the local social issues affecting patients, providing a clearer picture for healthcare providers to plan timely diagnosis and treatment.

By incorporating personalized approaches that take into account an individual’s social context, providers can make strides in improving patient outcomes.

Screening Tools

Screening tools are the instruments that capture the nuanced social needs of patients, ranging from financial strain to social connections. They are used extensively in healthcare settings, with varying degrees of formality, to screen for social needs and connect patients to the necessary resources.

Effective tools must be easy to use, provide actionable data, and be supported by a robust referral network to achieve positive referral outcomes.

Interventions to Address Social Needs

Having identified the what and the how, we now turn our attention to the interventions that can be put into action to address the social needs we’ve highlighted. Such interventions are instrumental in mitigating adverse conditions like food insecurity, housing instability, and social isolation.

Resource Guides And Linkage Interventions

Resource guides and linkage interventions act as bridges, connecting individuals with the services they require, from healthcare to housing support. While providing information about available services is crucial, it is the follow-up and evaluation that truly measure the effectiveness of these interventions.

Personal assistance from navigators can significantly enhance the outcomes for patients compared to just providing resource information, especially when working closely with family physicians.

Personal Assistance Programs

Navigators in personal assistance programs are akin to compasses in the complex terrain of social services systems. They provide invaluable guidance, from advising on documentation to assisting with applications, offering a lifeline of support and follow-up.

Programs like Signallamp, which employ dedicated nurses to consistently work with the same patient panel, enhance patient satisfaction and retention.

Community Partnerships

Strong community partnerships amplify the efforts of addressing social needs by bringing together the collective resources and expertise of various organizations. These collaborations, whether with healthcare entities or social service agencies, provide a more comprehensive and sustainable approach to tackling social determinants.

Case studies, such as the ones from the RISE Summit and Ohio’s cross-plan collaborations, exemplify the transformative potential of these partnerships.

Challenges And Opportunities in Addressing Social Needs

As is often the case with initiatives that aim to transform society, addressing social needs is fraught with both challenges and opportunities. Healthcare organizations may wrestle with the definition of social determinants of health and face significant barriers such as inadequate funding and workforce shortages.

Yet, the push towards health equity and improving population health presents a clarion call for investment and innovation.

Capacity And Resources

The road to addressing social needs is one that requires significant resources, and the current landscape is marked by both resource constraints and workforce shortages that hamper effective implementation.

Some challenges include:

Longitudinal Approaches

Amidst these challenges, there lies an opportunity in adopting longitudinal approaches that offer continuous support and adapt to changing social needs over time. Such sustained strategies are still in their infancy within many healthcare organizations, but they are critical for managing social determinants effectively over the long haul.

Research And Innovation

Vital to the evolution of interventions addressing social needs is the role of ongoing research and innovation. With a focus on value-based plans, CMS is signaling a shift towards comprehensive care that includes social determinants, pointing to a future where healthcare is increasingly attuned to the broader context of patient lives.

Case Studies: Successful SDOH Initiatives

Examining the success stories of initiatives that have positively impacted social determinants of health lends practical insight into what works. Case studies serve as powerful testimonials to the efficacy of targeted strategies in real-world settings.

Housing First Programs

The Housing First model, which has transformed the lives of many by reducing homelessness and improving housing stability, is testament to the power of prioritizing an individual’s basic need for shelter. By providing permanent housing without preconditions, these programs offer a stable platform from which individuals can address other aspects of their lives.

Food Prescription Programs

Similarly, food prescription programs like Cambridge Health Alliance’s initiative have shown that improving access to nutritious foods, such as healthy meals, can lead to better diet quality and reduced food insecurity.

Programs that provide a monetary credit for fresh produce are also proving to be an effective way to combat food insecurity and improve health outcomes.

Employment Support Services

Employment support services demonstrate the critical role of stable work in achieving self-sufficiency and improving well-being. Models like the Individual Placement and Support approach have been effective in helping people with disabilities or severe mental illness find and maintain employment.

How Technology Can Aid in Addressing Social Needs

Illustration of interconnected digital devices aiding in care coordination

In the digital age, technology emerges as a powerful ally in the quest to address social needs. Healthcare organizations are leveraging various platforms to enhance care coordination, optimize chronic care management, and facilitate trust-based patient engagement.

Digital Care Coordination

Digital care coordination platforms enable a seamless flow of information across healthcare settings, ensuring that patient care is continuous and comprehensive. Providers can track interactions and progress, engage patients remotely, and integrate care plans with electronic health records for a holistic view of patient health.

Data Analytics

Data analytics provide the lens through which healthcare providers can discern patterns of health inequities and tailor interventions accordingly. Platforms like Mahalo Health enable real-time data analysis, enhancing the ability to:

By leveraging data analytics, healthcare providers can make informed decisions and drive positive change in healthcare delivery.

Telehealth Services

Telehealth services are revolutionizing access to healthcare, particularly for those who face challenges such as transportation barriers. By incorporating programs that facilitate remote monitoring and engagement, healthcare providers can ensure that care is accessible, timely, and effective.

The Role of Policy in Addressing Social Needs

Policies provide the framework within which efforts to address social needs are structured and implemented. They have the potential to create systemic changes that support equitable access to resources and services, thereby enabling communities to thrive.

Medicaid Services And Funding

Medicaid services and funding are pivotal in ensuring that the most vulnerable populations have access to both health and social services. Expansion of Medicaid has been instrumental in increasing access to healthcare for low-income individuals, addressing many of the social needs that can lead to health disparities.

Moreover, the CMS has introduced flexibility in Medicaid funding, enabling states to tailor their services to meet health-related social needs more effectively.

Public Health Policies

Public health policies that focus on health equity can significantly improve overall health outcomes within populations. By promoting preventive measures such as vaccination and regular health screenings, these policies can advance health equity across different demographics.

Legislation that prioritizes health equity is essential for driving systemic changes in healthcare delivery and resource distribution.

Advocacy And Legislation

Advocacy plays a crucial role in bringing social determinants of health to the forefront of policy agendas. Community-based advocacy efforts can be powerful in shaping legislation to support more comprehensive care programs, ensuring that social needs are adequately addressed within healthcare frameworks.


As we conclude our exploration, it’s evident that addressing social needs in healthcare is a multifaceted endeavor that requires a concerted effort from individuals, communities, and organizations. By understanding and defining these needs, assessing them accurately, and implementing targeted interventions, healthcare systems can make significant strides in improving outcomes. While challenges such as capacity and resource limitations persist, the successful initiatives and technological advancements provide a beacon of hope for a future where health equity is the cornerstone of society.

Frequently Asked Questions

What Are Social Needs in the Context of Healthcare?

Social needs in healthcare refer to unmet material needs such as safe housing, sufficient food, and stable employment, which are crucial for maintaining good health. These needs are at the individual or family-level, and they are essential for overall well-being.

How Do Social Needs Affect Health Outcomes?

Unmet social needs can lead to increased use of emergency services, poor chronic disease management, and overall worse health outcomes due to the stress and hardships associated with insecurity in basic necessities. It is important to address social needs to improve health outcomes.

Why Are Community Health Assessments Important?

Community health assessments are important because they help identify specific barriers to health within a community, enabling tailored interventions and more effective collaboration with community organizations (source).

Can Technology Really Help Address Social Needs?

Yes, technology can indeed help address social needs by improving care coordination, offering real-time data analytics, and enabling access to care through telehealth services, particularly for individuals with transportation or mobility difficulties.

What Role Does Policy Play in Addressing Social Needs?

Policy plays a significant role in addressing social needs by creating frameworks for equitable access to resources and services and supporting funding initiatives to address root causes of health disparities. This ensures a more equitable and supportive society for all.