Introduction

The healthcare sector is increasingly recognizing the profound impact of social factors on health outcomes. This realization has fueled a significant surge in initiatives aimed at addressing social determinants of health (SDOH) within healthcare settings. From routine screenings for social needs to connecting patients with essential social services, these efforts represent a major shift towards integrated care models. This article delves into the expanding body of research that highlights the intricate links between social needs and health, examining the effectiveness of social needs interventions in enhancing health, optimizing healthcare utilization, and managing costs. While progress is evident, knowledge gaps and implementation hurdles remain. We argue that collaborative partnerships spanning healthcare, public health, and social services are crucial to build upon current momentum. Such collaborations can strengthen social safety nets, modernize social service delivery, and strategically reallocate resources to effectively address the social determinants of health and improve overall population well-being.

Efforts to tackle social determinants of health, a longstanding concern for public health experts, have gained renewed impetus thanks to heightened attention and substantial investments from the healthcare industry. This increased focus is driven by various factors, including the Affordable Care Act and a growing understanding of the critical role SDOH plays in overall health. This article provides a comprehensive review of the burgeoning research landscape that underpins these efforts to address SDOH in both clinical and community contexts. It identifies crucial gaps in our current understanding and explores promising avenues for innovative scientific approaches to effectively address social needs within the framework of healthcare programs.

The World Health Organization (WHO) defines SDOH as the political, social, and economic forces that shape health by influencing the conditions in which individuals live. These broad determinants operate at a systemic and policy level, impacting everyone in society and either exacerbating or mitigating inequities in vital areas such as housing, education, employment, wages, and access to opportunities. For individuals facing systematic disadvantage, the downstream consequences of SDOH often manifest as unmet social needs. These can include precarious, unaffordable, or substandard housing, food insecurity, unemployment, lack of accessible and quality childcare, or difficulties in affording essential utilities.

The WHO’s landmark “Closing the Gap” report (2008) proposed a three-pronged approach to tackling social determinants of health and achieving health equity: (1) improving daily living conditions; (2) addressing the unequal distribution of power, money, and resources; and (3) systematically measuring and understanding SDOH and evaluating the impact of interventions. Their conceptual framework positions healthcare systems as an intermediary determinant, suggesting that healthcare interventions, through intersectoral collaborations like providing food and transportation assistance, can play a role in mitigating inequities in “material circumstances,” such as housing, financial stability for food and clothing, and safe neighborhood environments.

The healthcare sector’s growing engagement with SDOH aligns closely with the WHO model and recommendations. It involves taking responsibility for measuring the problem through social needs screening, assessing the impact of interventions by tracking outcomes, and focusing on material deprivations. Castrucci and Auerbach (2019) rightly distinguish between broad SDOH and person-level experiences, arguing that issues like food and housing insecurity are more accurately termed individual social needs. While the term SDOH is still sometimes used in healthcare contexts to describe these individual needs, the term “social needs” is increasingly adopted as a more precise shorthand for unmet material needs experienced by individuals.

The increasing momentum to address social needs within healthcare settings is now evident in several routine practices. National surveys of Medicaid managed care plans, hospitals, and health systems indicate that individual-level strategies, particularly social needs screening and referrals to social services, are becoming increasingly common. However, the implementation is not uniform, with many healthcare organizations lacking formalized screening and referral processes, and adoption rates appearing lower in resource-constrained settings. The growing interest and investment in screening and referral have spurred the development of numerous technology platforms designed to streamline the process of addressing social needs.

Beyond individual-level approaches, many larger health systems are also investing in community-level and structural solutions. A study of 57 health systems revealed that $1.6 billion was allocated to housing interventions between 2017 and 2019 alone. These interventions included constructing affordable housing for homeless patients and high healthcare utilizers, assisting employees with home purchases in revitalization areas, and implementing eviction prevention programs. Although often pilot projects undertaken by larger health systems in partnership with community organizations, these substantial investments signal the potential for impactful multi-sector collaborations.

However, these partnerships might still be the exception rather than the rule. A national survey indicated that only 30% of hospitals and health systems reported fully functional formal partnerships with community-based social needs providers, and a significant 70% lacked dedicated funding to address social needs comprehensively for their target populations. Furthermore, many health systems likely lack the necessary community-level social needs data to inform investments effectively. Studies reveal that SDOH information remains the least developed component of Community Health Needs Assessments, which are mandatory for 501(c)(3) hospitals.

The scientific literature on healthcare initiatives addressing SDOH is heavily weighted towards research on individual social needs, which is the primary focus of this article. With a significant number of new studies on social needs interventions emerging monthly, special journal supplements dedicated to social needs research, and a growing body of evidence reviews, it is crucial for public health professionals to understand this evolving research and practice. It’s important to recognize its complementarity with broader public health efforts to address SDOH and the opportunities it presents for partnerships to improve population health and reduce health disparities.

Building upon this expanding research base, we aim to describe the social needs experiences of diverse populations, explore the impact of social needs on health, and evaluate the effectiveness of interventions targeting social needs in improving health outcomes, healthcare utilization, and costs. Finally, we will identify persistent knowledge gaps and implementation challenges, proposing future directions for a robust science of social needs in healthcare programs.

Assessing Social Needs in Health Care Programs

While community-level indicators are valuable, social needs are most frequently assessed at the individual level using self-reported data. Healthcare organizations have a long history of screening for specific issues like interpersonal safety within particular clinical populations or settings. Modern social needs screeners are increasingly multidimensional, utilizing various tools that differ in length, timeframes, and the range of needs assessed.

In 2015, the Institute of Medicine recommended 11 key measures, including race/ethnicity, education, financial strain, stress, depression, safety, substance use, physical activity, and social connections. The Centers for Medicare and Medicaid Services (CMS) measure encompasses five domains—housing, food, transportation, utilities, and safety—using 10 items. The American Academy of Family Physicians (AAFP) expanded on the CMS measure by adding questions about education, employment, financial insecurity, and childcare needs. The Health Leads screening tool further assesses the urgency of needs and whether patients require assistance with health literacy. The PRAPARE tool includes items on incarceration history, stress levels, and social connectedness.

Across these tools, common items assess needs related to food, utilities, housing, transportation, and safety. Screening often prioritizes aspects of need that align with healthcare organization priorities or perceived areas of influence. For example, housing stability is more frequently assessed than housing quality, despite both impacting health. Many tools lack open-ended questions to capture additional patient-identified needs, potentially limiting patient-centeredness.

Beyond assessing needs, some screeners, like those from AAFP and Health Leads, gauge patients’ desire for assistance. Research indicates that while patients generally view social needs screening in healthcare as appropriate, not all desire help from healthcare teams to address these needs, sometimes perceiving it as outside the scope of medical care. Correspondingly, only 40-60% of individuals reporting a need agree to participate in social needs programs.

Some screeners include items identifying non-modifiable factors that could influence service eligibility, such as incarceration history or veteran status. The use and interpretation of such data require careful consideration to avoid unintended consequences, such as biased treatment or long-term stigmatization within electronic medical records.

While most screeners are designed for adults, many have been adapted for or administered to parents of pediatric patients. A recent review identified 11 pediatric social needs measures, primarily focusing on family-level needs.

Significant variability exists in the wording, response formats, timeframes, and administration procedures of social needs screening items. These inconsistencies hinder direct comparisons across studies. Some items assess multiple needs within a single question, making it difficult to pinpoint specific unmet needs. Others require respondents to link social needs causally to health outcomes. Timeframes also vary, ranging from days or weeks to a year.

Currently, there is no consensus on the optimal approach to social needs screening, including who, when, where, and how often to screen. Screening occurs in diverse healthcare settings, with varied populations, modalities, and implementers. Some experts caution against selective screening based on demographics or residence, as it could erode patient trust and worsen disparities. Universal screening is suggested as a way to mitigate this risk.

Prevalence of Social Needs Addressed by Health Care Programs

Unmet social needs are prevalent among marginalized populations. Prevalence studies largely rely on self-reported screening data, though some utilize administrative data or helpline requests. Studies often report individual need prevalence, as well as the total number of needs per person, including the percentage experiencing 0, 1, or 2+ needs. Table 1 illustrates the prevalence of selected social needs across diverse populations and healthcare settings.

Table 1. Sample of studies that report prevalence of social needs.

Study information	Social needs prevalence	Individual social needs
N	Study population	Social needs assessed
Clinical setting
Berkowitz, 2016	416*	Urban primary care
Bisgaier, 2011	1,506	Urban emergency dept
de la Vega, 2019	1,696	Urban adult primary care
Garg, 2015	336	Mothers at urban CHCs#
Gottlieb, 2016	1,809	Parents at safety net hospitals
Hassan, 2015	401	Urban young adult clinic
Heller, 2020	24,633	Primary care patients
Page-Reeves, 2016	3,048	Primary care patients
Polk, 2020	10,916	Patients at pediatric practices
Community or non-clinical setting
Emechebe, 2019	13,708*	MCO helpline callers#
Kreuter, 2020 (Study 1)	1,898	2-1-1 callers
Kreuter, 2020 (Study 3)	10,267	Medicaid enrollees
Kreuter, 2020 (Study 4)	1,370	2-1-1 callers
Schickedanz, 2019	3,721	Potential high use patients
Thompson, 2019	1,214	Medicaid enrollees

*N only includes participants who reported at least one social need to reflect how prevalence data were reported in the study.

CHC = Community Health Center; MCO = Managed Care Organizations.

NA = data not available (i.e., not reported)

ND = no data collected

Studies reveal that participants frequently experience multiple social needs, often two or more, even when screeners assess a limited number of needs. Studies screening broader patient populations tend to find fewer needs per person. Table 1 categorizes studies into clinical and community/non-clinical settings. Clinical setting studies assess needs during healthcare visits, often in person but sometimes via online surveys. Community/non-clinical studies assess needs independently of healthcare, among individuals seeking assistance through helplines, or via phone outreach to health plan members.

Housing, food, childcare, and financial strain are among the most prevalent social needs. In Table 1, 5-43% of participants in clinical settings reported housing instability. Other housing-related needs, like low-quality housing or overcrowding, are often even more prevalent when assessed, though many studies focus solely on housing stability. Food insecurity, defined variably as reduced food intake, meal skipping, or running out of food, is another highly prevalent need. In Table 1, 6-41% of clinical setting participants reported food-related needs.

Childcare needs are highly prevalent among adults with young children, though less so in general population screenings. In Table 1, 29-50% of adults with young children reported childcare needs, compared to only 2-3% in general population studies. General financial strain is consistently identified across studies, although varying screening questions make direct comparisons challenging. Kreuter et al. found that lacking funds for unexpected expenses was the most prevalent need (47-89%) across four studies. Other studies also identify financial strain as the most common social need, whether related to healthcare costs or broader income and employment concerns.

These prevalence rates for housing, food, childcare, and financial needs among low-income samples are generally higher than population-wide estimates from public health surveillance. In the U.S., slightly over 10% of households experience food insecurity annually. Around 7% are housing cost-burdened, and approximately 0.2% experience homelessness.

The most prevalent needs can vary by study setting. Helpline callers, for example, more commonly report utility and transportation needs compared to healthcare settings. This may be because healthcare screenings often focus on transportation specifically for healthcare access, and individuals arriving for healthcare visits have, at least temporarily, overcome transportation barriers.

Studies across settings have identified lower income, less education, and unemployment as common correlates of increased unmet social needs. However, findings are mixed for other demographics. Some studies report older participants experiencing more needs, while others find more needs among younger participants. Conflicting findings also exist regarding the association between gender and social needs.

While national data suggests racial and ethnic minorities are at higher risk for food and housing insecurity, social needs studies have not consistently found this association. One study of helpline callers found White participants more likely to have social needs, while others found no association or that Black or Hispanic participants were more likely to have needs. These inconsistencies may be due to variations in study samples and measurement approaches.

The Link Between Social Needs and Health Outcomes in Health Care Programs

Globally and within the U.S., broader social determinants like income and education are strongly linked to health outcomes, including chronic diseases and mortality. A growing body of research also connects individual social needs to a range of health outcomes, from health behaviors to mortality and healthcare utilization and costs. Material need has been associated with reduced access to care, delayed diagnosis and treatment, and increased hospitalization, length of stay, readmission rates, complications, and mortality. These associations can be mediated by lack of health insurance. However, much of this research is cross-sectional, limiting the ability to establish causality and raising the possibility of bidirectional or reverse causality. For example, longitudinal studies show that basic needs insecurity predicts depressive symptoms, but also that depressive symptoms can predict basic needs insecurity.

Many studies have examined the relationship between a single social need, particularly food or housing insecurity, and specific health outcomes. Food insecurity is linked to negative health consequences across the lifespan, including obesity, stunting, cardiometabolic disease, sleep problems, inflammation, poor diabetes control, and poor child health. Food insecurity is also associated with higher healthcare expenditures in the general U.S. population, while participation in SNAP is linked to lower healthcare expenditures among low-income adults.

Housing insecurity and homelessness are also associated with adverse health outcomes in both adults and children. Low-income adults receiving rent assistance are significantly less likely to rate their health as fair or poor compared to those on waiting lists. Among Canadian adults with HIV, unmet needs for food, clothing, or housing were associated with lower physical and mental health-related quality of life.

Strong evidence supports a dose-response relationship between social needs and health. Increased social needs are associated with worse physical and mental health, more chronic conditions, depressive symptoms, and higher perceived stress. In children, higher levels of unmet needs are linked to lower levels of overall wellness.

Social needs are also associated with various health-related behaviors, including smoking, drug use, poor diet, physical inactivity, insufficient sleep, and avoidance of preventive healthcare. For many of these behaviors, the association with social needs exhibits a dose-response gradient.

While most research linking social needs to health behaviors and outcomes is cross-sectional, longitudinal studies also confirm that social needs predict negative health outcomes. In community-dwelling adults, higher unmet social needs predicted increased depressive symptoms, physical function problems, and higher mortality.

This accumulation of evidence has led the National Academies to conclude that addressing social conditions and reducing social vulnerability is crucial for improving health and reducing health disparities.

Further research is needed to elucidate the mechanisms through which unmet needs impact health. Proposed models suggest indirect effects through reduced stress, fewer competing demands, improved adherence to medical recommendations, better health behaviors, improved physiological functioning, and enhanced psychosocial well-being.

Social Needs Interventions within Health Care Programs

Social needs interventions range from those addressing a single need to increasingly comprehensive approaches targeting multiple needs identified through screening. Simpler interventions involve distributing resource guides with limited follow-up. More comprehensive “linkage” interventions include systematic screening followed by referrals to community organizations or co-located services.

However, service eligibility criteria and resource limitations at social service agencies mean that referrals do not guarantee needs will be met. While some patients may self-resolve needs using resource information, others require personalized support from case managers or social needs navigators. Navigators, often affiliated with healthcare organizations or community agencies, provide ongoing support and follow-up. While navigation is often offered to high-acuity patients, universal navigation programs are less common.

Literature reviews have summarized various social needs interventions. Most studies report need prevalence and referral completion rates, with fewer reporting health outcomes or cost savings. Results vary by need addressed. Housing interventions have shown effects on health outcomes and costs, while studies on nutrition, income, or care coordination are less numerous and have mixed results. Interventions targeting housing and asthma triggers have shown promise in reducing urgent care utilization and improving symptom-free days and quality of life. Integrating social work into primary care has demonstrated positive effects on subjective health, chronic disease self-management, and reduced psychosocial morbidity and barriers to care.

Social needs navigator programs addressing multiple needs also show promise. Studies have shown that navigators improve child health outcomes compared to resource guides alone, and that community health worker navigation is more effective and cost-effective than standard care in reducing hospitalizations and costs. Clinic-based navigation and community-based navigation have shown similar psychosocial outcomes. Health Leads programs have shown improvements in blood pressure and cholesterol among participants. Medical-legal interventions for parents of newborns have increased access to support services, immunization rates, preventive care, and reduced ED visits.

While individual studies are promising, reviews highlight methodological limitations. Many trials use screeners with unknown reliability and validity, focus on process outcomes, lack large samples or cost-effectiveness analyses, and have limited comparison groups and follow-up periods. Pre-post designs in high-risk populations may be confounded by regression to the mean. It’s also important to assess whether utilization reduction interventions are truly beneficial and do not inadvertently reduce preventive care.

Beyond effectiveness, research is needed to understand how these interventions work. Potential pathways include increased resource access, reduced patient stress, improved provider care, and reduced provider burnout. The latter two provider-related pathways require further research. Understanding patient social needs might influence provider approaches to medication management or behavior change counseling, and healthcare system support for social needs may reduce provider stress. Exploring these mechanisms will advance the science and practice of addressing social needs in health care programs.

Alt text: Healthcare provider in a clinic setting discussing health care programs with a patient, emphasizing patient-centered care and accessible health information.

Challenges and Next Steps for Health Care Programs Addressing Social Needs

A key assumption of screening and referral interventions is sufficient capacity within social service agencies. Longitudinal studies reveal that only about one-third of referrals result in actual assistance. Agency capacity varies by community and need type, with urban areas and food-related needs often better served than rural areas or housing needs. Screening and referral may be unsuitable for needs where service capacity is limited.

Our understanding of the dynamic nature of social needs is limited. Current assessment is often sporadic, with long gaps between screenings. This is problematic if needs are not stable, and evidence suggests financial needs, at least, can fluctuate significantly. Dynamic needs may require longer-term interventions like ongoing navigation rather than one-time referrals. Understanding patterns and sequences of needs could enable proactive interventions and identify population-level issues requiring upstream solutions. Longitudinal research on dynamic needs and their interrelationships with health is crucial.

Current interventions often treat each reported need as independent, potentially missing synergistic effects and inefficiently using resources. For example, utility assistance and food needs are often correlated. Addressing one need, like transportation, might free up resources to address others. Future research should explore integrated strategies that address multiple needs efficiently.

Social needs may cluster within specific population subgroups. For example, women with children might disproportionately experience housing space and utility needs, while younger men may face safety and housing insecurity, and older adults in poor health may struggle with food and transportation. Hudson and colleagues argue for tailored interventions for Black men addressing their specific social, legal, and economic needs. Targeted intervention packages for specific subgroups could be more effective than one-size-fits-all approaches. Research comparing these approaches is needed.

Understanding complex relationships between needs could also streamline screening. For instance, individuals reporting transportation needs may also be more likely to have food or healthcare access needs, even if not explicitly seeking help for those through a specific helpline. Identifying such interdependencies could lead to more efficient and informative screening tools.

These considerations—community capacity, dynamic needs, need clusters, and efficient screening—have practical implications for intervention delivery. They inform decisions about which needs to target, when, for whom, and with which strategies, to maximize efficiency, cost-effectiveness, and sustainability.

However, even optimized social needs interventions in healthcare must be viewed within a broader context and enhanced through partnerships and policies. Not everyone has health insurance or healthcare access. Integrating healthcare and social services offers a spectrum of collaborative possibilities. Screening and referral programs represent a lower level of integration compared to community-wide collaborations benefiting all, not just health plan members. Competing health plans with similar referral programs may even compete for the same limited social services.

Addressing social needs effectively and sustainably is complex and potentially costly. Health benefits may be modest or long-term, especially if upstream causes remain unaddressed. Healthcare sectors may lose interest if perceived ROI is insufficient or if they deem others better suited to address social needs. This would be a significant missed opportunity. Sustaining healthcare sector engagement is paramount. Public health professionals must actively participate in cross-sector, multi-level community efforts to improve population health and reduce disparities by addressing SDOH and social needs in collaboration with healthcare organizations.

All levels of intervention will be more effective with investments in and modernization of the social service sector, including social safety net policies and resource allocation. As healthcare interventions evolve, public health professionals must also work to shape upstream SDOH that drive both health disparities and the unequal distribution of unmet social needs.

Contributor Information

Matthew W. Kreuter, The Brown School, Washington University in St. Louis.

Tess Thompson, The Brown School, Washington University in St. Louis.

Amy McQueen, School of Medicine and The Brown School, Washington University in St. Louis.

Rachel Garg, The Brown School, Washington University in St. Louis.

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