How Current Prescriptions for Addressing Health-Related Social Needs Fall Short

Kenny Lin, MD, MPH
Posted on July 24, 2023

According to one recent estimate, cumulative poverty (earning less than 50% of median household income in at least one of the past 10 years) and current poverty are the fourth and seventh leading causes of death in the United States, respectively, on par with obesity and dementia and behind only heart disease, cancer, and tobacco use. The knowledge that financial insecurity and resulting social needs have profound effects on health has inspired organized medicine initiatives aimed at identifying and meeting those needs, such as the American Academy of Family Physicians’ (AAFP) The EveryONE Project.

In a 2019 AFP editorial, Dr. Kevin Sherin and colleagues asserted that “family physicians have a leadership role in identifying and addressing issues that affect patients beyond the clinical setting.” They highlighted the AAFP’s Neighborhood Navigator tool (formerly Aunt Bertha/findhelp), which clinicians and primary care teams can use to link patients to available community resources for different types of social needs. A recent Graham Center Policy One-Pager found that the most common Neighborhood Navigator searches since 2018 were for food, housing, and health care.

Some practices and health care systems have begun screening patients for social needs using print or electronic health record-embedded questionnaires. Two articles in FPM (A Practical Approach by Drs. David O’Gurek and Carla Henke and Screening in Daily Practice by Dr. Vinita Magoon) reviewed the logistics of designing a practice workflow for screening and coding and payment considerations. Gaps in the evidence regarding the effectiveness of screening remain, however. Although the U.S. Preventive Services Task Force considers social risk in the majority of its recommendation statements, it has not found sufficient evidence to recommend screening for social needs. In a 2019 editorial, Dr. Alex Krist and colleagues discussed the research that still needs to be performed:

These recommendations highlight what is needed before recommending routine screening for social needs: an accurate screening test to identify patients with the social need, an effective treatment to address the social need once identified, and evidence demonstrating a meaningful health outcome improvement for patients. 

In 2017, the Centers for Medicare and Medicaid Innovation launched the Accountable Health Communities Model, a five-year demonstration project that evaluated whether a proactive approach to identifying and addressing patients’ health-related social needs could reduce care utilization and spending. Although primary care referrals to community services increased for eligible patients, an independent evaluation found that they were no more likely to utilize these services or have their needs met than patients in a randomized control group. Patients often had a hard time reaching community service providers, were deemed ineligible for their services, or did not receive sufficient help from the provider to resolve their need (e.g., continued to have food insecurity despite receiving food assistance). A Health Affairs Forefront commentary pointed out the need to solve the “last mile problem”:

Even when patients received navigation and social service providers had capacity, gaining access to timely social services required some combination of hours of free time to make phone calls, important paperwork at one’s fingertips to apply, and a PhD in social work to understand eligibility rules.… Meaningful navigation support must … not only connect patients to appropriate services, but to ensure the patient’s social needs are met.

Equally important, many community organizations have inadequate resources and funding to serve their populations. A microsimulation study in JAMA Internal Medicine estimated the costs of implementing interventions to address social needs identified in primary care practices. Existing federal funding mechanisms (e.g., the Supplemental Nutritional Assistance Program) covered less than half of the cost of providing food, housing, transportation, and care coordination support for patients with at least one of these four needs. Clearly, the health care system cannot address health-related social needs on its own. As the unwinding of Medicaid’s COVID-19 continuous enrollment condition (which expired on March 31, 2023) proceeds, the need for social policy as health policy has never been greater.