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New 4-Part Framework Helps Physicians, Community Partners Address Social Determinants of Health

Analysis  |  By Christopher Cheney  
   July 03, 2019

A new proposal provides guidance for partnerships between primary care practices and community-based organizations to address social needs.

The United Hospital Fund has developed a four-part framework for healthcare organizations to address social determinants of health in the communities they serve.

Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.

The New York­­–based United Hospital Fund has released a new report that features a four-part framework to address SDOHs with primary care practices at the frontline of the effort.

"Primary care practices are trusted sources in addressing the health needs of patients. They are uniquely positioned to screen for, and respond to, the social needs of their patients. Often, that entails referring the patient to community-based organizations (CBOs) that can provide services to meet the unique needs of that patient. In a perfect world, CBOs would report back to the primary care practice on the outcome of referrals, so the practice could be sure that documented problems are being addressed," the report says.

The four parts of the United Hospital Fund's proposed framework are as follows:

1. Screening for SDOHs

The first step in adopting the framework is deciding which SDOHs that a primary care practice will target for screening, a co-author of the United Hospital Fund report told HealthLeaders.

"Practices should consider the social determinants prevalent in the population they serve and whether those SDOH needs are issues that the practice can assess and refer for within their workflow constraints," Program Manager Kristina Ramos-Callan says.

Also, there are two primary considerations when matching a screening tool with a patient population, she says. "Screening tools need to be a good cultural fit—the questions and their phrasing need to be relevant and asked in culturally sensitive and acceptable ways. Practices also need to consider whether the questions they are asking require additional training of their staff or the development of training tools such as scripts or prompts for administering screens."

In choosing staff to conduct the screening, practices need to consider current job responsibilities, staff capacity to effectively screen and follow up, and the staff members' existing relationship with patients, Ramos-Callan says.

"Is the staff member a routine contact for that patient on the care team? Does that staff member have the time or inclination to help when it is immediately needed? Is that staff member trained in identifying issues that require a rapid response, or able to meet patients where they are in prioritizing among multiple needs?" she says.

2. Community organization referrals

Selecting community-based organizations for SDOH referrals can be a daunting task for primary care practices, according to the United Hospital Fund report. "There are myriad CBOs, ranging from large, citywide, well-developed, and multi-service organizations to small providers that focus on specific niche services in a specific community. Understanding that ecosystem and how to refer patients for specific services is a serious challenge for practices," the report says.

Two community health centers that helped develop the United Hospital Fund framework decided to pick large, multiservice organizations as their community partners. This approach allowed the health centers to work with familiar community organizations that had the scope and ability to tackle a wide range of social needs.

3. Getting patients needed services

Ideally, the report says making referrals and providing services to patients includes several key components:

  • Effective screening
  • Appropriate and efficient referrals
  • Patients follow through on referrals
  • Rendering of services
  • Fully addressing SDOHs
  • Primary care practices and community partners should be aware of how a case is resolved

4. Informing primary care practices about referral outcomes

Primary care practices and their community partners need to track the status of patients throughout the referral process and, hopefully, resolution of a patient's SDOH needs, the report says.

Social needs should be entered in a primary care practice's electronic medical record, the report says. If the EMR is incapable of collating and tracking social needs, the information should be entered into a designated registry or care management system so staff can track screening results and flag social needs for further action and follow-up during future patient visits.

It is essential for primary care practices and community organizations to bridge the gap between the practice's EMR and record systems at CBOs. "The referral and feedback loop must include the ability to flag and report … outcomes, so the CBO and/or practice can follow up as provided for in the workflow," the United Hospital Fund report says.

Beyond the framework

Changes in healthcare policy and health plans are needed to support the proposed SDOH framework, the report says.

Four essential components must be addressed to enable primary care practices and their community partners help meet the social needs of patients, according to the report:

  • Development of standardized and interoperable information platforms to coordinate the efforts of practices and their community partners
  • Expansion of the social service sector to accommodate increased demand for social-need resolution
  • Crafting new value-based payment models to help finance expansion of social needs services
  • Assessment of partnerships between practices and their community partners to inform discussions about new payment models

Christopher Cheney is the CMO editor at HealthLeaders.


Development of standardized and interoperable information platforms is essential to coordinate the efforts of physician practices and their community partners to address patients' social determinants of health.

To ensure that referrals to community partners are successful, primary care practices need to be informed about social-need referral outcomes.

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