CIN Resource Page: Addressing Social Needs That Impact Health


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 CIN@ucsf.edu.

Getting Started

Making the Case

Screening and Implementation Tools

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.

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)
  • Social Needs Roadmap
    A library of resources to guide health care organizations in launching partnerships that address patients’ social needs.
  • 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 low-income and vulnerable populations.
  • 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 low-income families’ financial security, home ownership, and related financial goals. Engages policymakers.

Other Resources

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