Addressing Patients’ Nonmedical Needs: Defining the Role of Health Care Organizations, and Providing Guidance for Integrating Services


Housing, food security, and access to transportation are among the social needs shown to have a significant impact on people’s use of health services and the health outcomes they experience. Recent insurance coverage expansions and the move toward value-based payment models have led an increasing number of delivery system leaders to recognize that their organizations will need to address these nonmedical factors to meet quality, cost, and health outcome goals. This project will synthesize practical guidance on integration of nonmedical services with health care. Informed by a literature review and consultations with stakeholders and experts, the coalition will: 1) identify steps that providers and health systems can take to: systematically screen patients for unmet social needs, create local resource directories; build relationships with community resources; train health staff on connecting patients to services; and evaluate impact on patient experience, cost, and utilization; 2) draft a toolkit with training modules for each of these key steps; and 3) disseminate the toolkit broadly to health care leaders, policymakers, measurement and accreditation organizations, payers, and professional organizations.

Grant Details

Grantee Organization:
Health Leads, Inc.
Principal Investigator:
Rebecca Onie, J.D.
Award Amount:
Approval Date:
April 12, 2016
Related Topics
Health Care Delivery

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