CIN Resource Page: Addressing Social Needs That Impact Health


Social and environmental factors linked to poverty, including a lack of housing, nutritious food, or transportation, can be harmful to health. Addressing social needs that impact health, one of the California Improvement Network’s priority areas, by integrating social care into health care delivery is more relevant than ever.

This page provides tools and strategies for effectively and sustainably addressing patients’ social needs, including prioritizing social needs strategies, supporting staff in effectively addressing social needs, and building partnerships with community-based organizations. These resources are intended for health care professionals who are decisionmakers at all levels, at commercial and safety-net provider organizations and health plans, to help build resilience, lead change, and inspire.

Resources listed on this page reflect the focus and interests of CIN partner meetings and will be periodically updated. They are organized reverse chronologically.

Resources cover the following topics:

Have a resource for this page? Please submit to [email protected].

Addressing Food Insecurity: Concrete Advice from Clinic Leaders
CCI has created a start-to-finish checklist of how to test, refine, implement, and track programs to combat food insecurity. See the 13 pointers they gathered from six Los Angeles-based, federally qualified health centers (FQHCS) to strengthen and expand their capabilities and infrastructure to assess and address this crucial social determinant of health. (Center for Care Innovations, June 2021)

Aligning Social Needs Work with CalAIM

California Advancing and Innovating Medi-Cal (CalAIM)
DHCS provides background on CalAIM, updates and progress, and a number of detailed documents with requirements and technical aspects, as well as information on workgroup meetings and how to stay involved in the CalAIM roll out. (California Department of Health Care Services, 2021)

Focus on CalAIM
This collection offers commentary, analysis, and resources to facilitate a robust discussion around the payment and delivery system reforms being considered through CalAIM, and pays close attention to efforts to align financial incentives to improve quality in Medi-Cal managed care and to integrate behavioral and physical health care delivery. (California Health Care Foundation, 2021)

CalAIM Implementation Timeline and Tracking Resources
ITUP provides synthesized details about CalAIM’s goals and useful tools to track other Department of Health Care Services initiatives, legislative, and budget items that will work in concert with the CalAIM initiative, as well as the implementation timeline for key initiatives such as Enhanced Care Management, In Lieu of Services, Behavioral Health Payment Reform, and more. (Insure The Uninsured Project, June 2021)

Determining Which Social Needs and Populations to Prioritize for Action

Coronavirus Disease 2019 (COVID-19): Social Health Playbook (PDF)
This document, by Kaiser Permanente, offers guidance on caring for patients with social needs in a COVID-19 context. The information in this document includes how to assess patients’ social needs, connect them to resources, and follow up with patients to ensure their needs were met. The target population for this information is frontline staff and other care team members performing care coordination or care management. (Kaiser Permanente, Oct. 9, 2020)

Cold Water or Rocket Fuel? Lessons from the Camden “Hot-Spotting” Randomized Controlled Trial
An overview of recent studies that have contradicted “hot-spotting”, a widely recognized intervention aimed at improving care for people with substantial health and social need. (Eric C. Schneider and Tanya B. Shah, Health Affairs Blog, Feb. 11, 2020)

Quantifying Health Systems’ Investment in Social Determinants of Health, by Sector, 2017–19
An article outlining the new social determinants of health programs between January 1, 2017 through November 30, 2019 to better understand the investment being made in community programs to improve health outcomes. (Leora I. Horwitz et al., Health Affairs, Feb. 2020)

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs and Generates Positive Return on Investment
Return-on-investment analysis that is based on a standardized community health worker intervention that addresses unmet social needs for underserved population to better understand a more accurate picture of the return-on-investment for social needs efforts. (Shreya Kangovi et al., Health Affairs, Feb. 2020)

Building Partnerships with Community-Based Organizations and Other Partners

Screening for Unmet Social Needs: Patient Engagement or Alienation?
This article offers guidance and pragmatic advice to help health care leaders make their social needs programs more patient centered and effective. The guidance offered in this article spans technology considerations, settings for effective social needs screening, and strategies for minimizing patient harm and traumatization. (Elena D. Butler, Anna U. Morgan, and Shreya Kangovi, NEJM Catalyst, July 20, 2020)

Free Doula Program for Black Moms-To-Be Gets New Life
Update on the new program HealthNet is funding to provide African American expecting mothers in Los Angeles County with a doula. (Mariana Dale, The LAist, Feb. 26, 2020)

Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health (PDF)
A framework designed to help primary care providers screen their patients for social needs that impact health and partner with CBOs who can address the needs. (Greogry C. Burke, Kristina Ramos-Callan, and Chad Shearer, United Hospital Fund, June 2019)

Working Together Toward Better Health Outcomes
This article provides information from more than 200 partnerships serving all 50 US states who share important lessons from partnerships that hope to improve access to care and make progress on social issues like food, education, and housing. (Elise Miller, Trishna Nath, and Laura Line, Center for Health Care Strategies, June 2017)

Partnership Assessment Tool for Health (PDF)
A strategy tool to guide partnerships between health care organizations and community-based organizations, with case studies and a 10-page report from a project where partnerships served low-income and vulnerable populations. (Partnership for Healthy Outcomes, 2017)