Lessons from a National Health Initiative that Helps Address Social Needs

The latest episode of On the Evidence focuses on a national initiative aimed at identifying and addressing non-medical factors that affect a person’s health. Doctors, nurses, and other health care providers can use a screening tool, such as a questionnaire, to uncover a patient’s health-related social needs, such as housing instability or food insecurity. Providers can then refer patients in need to community-based organizations with the resources and expertise to help.

The Centers for Medicare & Medicaid Services (CMS) developed one such screening tool as well as a guide to assist providers who use the tool. The guide was created for the Accountable Health Communities (AHC) Model, a program that includes 28 organizations across the country.

Because screening for health-related social needs has value beyond the AHC Model, CMS and Mathematica developed a public-facing version of the guide with promising practices to promote screening in a wider range of contexts.

This episode focuses on the screening tools and related guide as well as the larger question of how to address the root causes of health inequity that lead to the kinds of unmet health-related social needs these screening tools detect. Our guests for this episode are Natalia Barolín from CMS; Maureen Kirkwood and Rafael Castañon of Health Net of West Michigan (an organization participating in the AHC Model); Rachel Kogan of Mathematica, who helped write the screening tool guide; and Lee-Lee Ellis, a health researcher formerly at Mathematica who also helped draft the public facing version of the screening guide.

Listen to the full episode now.