Leveraging a Social Needs Framework to Accelerate Dissemination of Best Practices


Recent health care market forces, including new payment models that hold providers accountable for the total costs of care, have shed light on the social and environmental factors that affect people's health, beyond services and treatments. In 2016, the Centers for Medicare and Medicaid Services announced its Accountable Health Communities and Comprehensive Primary Care Plus pilots, both of which test ways to integrate patients' social needs into health care delivery. These trends have increased demand for new approaches, tools, and best practices for addressing patients' social needs. In the previous phase of this project, Health Leads developed practical guidance for health care organizations to help them identify patients' social needs and connect them to sources of support. Expected to be publicly available in September 2017, this web-based toolkit will feature a combination of screening instruments, data-driven program improvement metrics (rates of social needs screening, patients served, resource referrals, and connection to resources); information on community partnerships; and resources on organizational change management. The Health Leads team will continue to work with health systems to further test and refine this set of online resources, or "roadmap." Health Leads will establish a learning collaborative of 10 safety-net health systems to test and improve ways to address patients' social needs in the context of health care delivery. Of the 10 participating organizations, four will be health systems with whom Health Leads has worked in the past and six will form a new cohort that will pilot social service integration for the first time. Throughout the course of the collaborative, the project team will hold in-person meetings, provide one-on-one guidance, recruit experts, measure participants' progress, and disseminate results. Lessons from the collaborative will help to refine and improve the online roadmap, a robust platform that will include tools, best practices, research, data, and peer learning. This project has the potential to help health systems and community-based organizations better meet patients' social needs while spreading best practices broadly across the sector.

Grant Details

Grantee Organization:
Health Leads, Inc.
Principal Investigator:
Rebecca Onie, J.D.
Award Amount:
Approval Date:
July 11, 2017

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