CIN Resource Page: Making the Case to Address Social Needs


To improve population health and manage total cost of care, medical providers must support patients, families, and communities in addressing social needs that impact health. This resource page from the California Improvement Network (CIN) consists of a short list of relevant and timely resources to help health care organizations in this complex endeavor, regardless of the organization’s history of effort and investment.

Resources are organized reverse chronologically and cover the following topics:

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

Getting Started

Social Determinants of Health 101 for Health Care: Five Plus Five
An orientation to addressing social needs that impact health. (Sanne Magnan, National Academy of Medicine, Oct. 9, 2017)

Making the Case

Housing Is Health Care: The Impact of Supportive Housing on the Costs of Chronic Mental Illness
This study examines how housing and in-home supports affect public spending on individuals with chronic mental illness in Maricopa County, Arizona. It does so through a comparative analysis of average costs per person per year across three housing settings: permanent supportive housing, housing with unknown in-home support, and 24/7 in-home support to individuals who have CMI and high support needs during the period of 2014-2019.  (Julia [Chrissie] Bausch, Alison Cook-Davis, Benedikt Springer, Arizona State University Morrison Institute for Public Policy, May 2021)

Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case
A 2018 guide from the KPMG Government Institute and The Commonwealth Fund to support health plan and provider investments in services that address social needs that impact health. (The Commonwealth Fund, Mar. 2018)

ROI Calculator for Partnerships to Address the Social Determinants of Health
Generates program financing models based on variables for revenue increases and decreases, and costs of program components like staff salaries. Supported by The Commonwealth Fund and created by Victor Tabbush at the University of California, Los Angeles, from an earlier version for complex care programs.

Screening and Implementation Tools

PRAPARE for Social Determinants of Health (YouTube video) (California Primary Care Association, Apr. 19, 2018)

Social Interventions Research and Evaluation Network (SIREN) Screening Tools
Catalog of 15 screening tools, in addition to a comparison of the most widely used social health screening tools. Summarizes each tool’s intended population or setting, domains/topics covered, and number of questions dedicated to each domain.

Social Interventions Research and Evaluation Network (SIREN) Implementation Resources
Nine toolkits that provide recommendations and guidance for implementing social needs screening and interventions. Most focus on food security and housing.

Referral and Coordination Platforms

2018 Buyer’s Guide: Social Innovation Technology for Health Care
A buyer’s guide from Patchwise Labs that examines policy and market trends in the emerging social needs technology industry and includes profiles of six leading vendors in the market. Sign up via email to access the executive summary. (Patchwise Labs, 2018)

Aunt Bertha
Helps users find food, health, housing, and employment programs based on zip code. Free to search. Paid subscriptions tailored to different org types allows for closed-loop referrals, reporting, other benefits.

One Degree
Makes it easy to find community and nonprofit resources, get personalized recommendations, keep track of opportunities, and share them with others.

Healthify
Helps health plans and providers address social needs through referrals and coordination with services such as housing, food, and low‐cost behavioral health services. Home of the platform Purple Binder.

Health Leads
Helps health systems create models for integrating patient social needs into care, using a full spectrum of tools, education, and consulting.

Unite Us
Builds coordinated care networks of health and social service providers. With Unite Us, providers across sectors can send and receive secure referrals, track every person’s total health journey, and report on tangible outcomes across a full range of services in a centralized, cohesive, and collaborative ecosystem.

Building Effective Partnerships

Opportunities for Medi-Cal to Support Community Health Initiatives
Explores ways that Medi-Cal managed care plans and community health initiatives (e.g., the California Accountable Communities for Health Initiative) can align resources and partner more effectively to achieve common priorities such as improving health equity. (John Snow, Inc. and Center for Health Care Strategies, May 2018)

Partnership Assessment Tool for Health
A strategy tool to guide effective partnerships between health care organizations and community-based organizations, with case studies and a 10-page report from a project where partnerships served vulnerable populations and those with low incomes.

Social Needs Roadmap
A library of resources to guide health care organizations in launching partnerships that address patients’ social needs.

Working as a System to Optimize Family Wellness
A guidebook for taking a learning-by-doing approach to addressing social needs that impact health. Describes the journey of eight multi-organization partnerships working to meet the medical and social needs of a defined population. One partnership featured: The Boys and Girls Club, a middle school, and a health center.

Supporting Financial Security

LIFT
An organization that partners with early-childhood organizations to engage and support parents and caregivers to plan for financial security, education, and employment.

Prosperity Now
An organization that works with service providers to support the financial security, home ownership, and related financial goals of families with low incomes. Engages policymakers.

Other Resources

State Payment and Financing Models to Promote Health and Social Service Integration (PDF)
Outlines the financing models state Medicaid programs can use to support health care providers’ efforts to integrate medical and social services. (Center for Health Care Strategies, Feb. 2015)

California Accountable Communities for Health Initiative
Curated materials and resources to support the understanding and development of the Accountable Communities for Health (ACH) model. Includes a searchable database organized into nine categories.

Health Begins
Consulting and resources to equip providers to design upstream solutions that improve health at lower costs.

Health Outreach Partners
A national nonprofit providing training, consultation, and information services to community‐based organizations striving to improve the quality of life of hard‐to‐reach populations.

National Center for Complex Health and Social Needs
Combines complex care and social needs efforts into a national network of conferences and expertise. A program of the Camden Coalition, Robert Wood Johnson Foundation, and other partners.

Root Cause Coalition
Focuses on health inequity and cross-sector partnerships, member-based network, including policy and advocacy.

Social Interventions Research and Evaluation Network (SIREN) Evidence Library
A searchable evidence library of resources that explore and assess health care–based interventions that address social and economic needs that impact health.

Several resources listed here are from CIN partner California Quality Collaborative.