Healthcare systems could benefit from knowledge sharing and systematic evaluations to achieve better success in social needs screening and intervention programs.
RT’s Three Key Takeaways:
- Targeted Focus – Programs that concentrated on smaller, targeted patient populations achieved substantially higher social needs screening and intervention rates than those serving general populations.
- Implementation Support – Clinics with added staffing and structured processes were more successful in screening and connecting patients to resources, though intervention effectiveness varied widely.
- Evidence Gaps – The review highlights limited and mixed data on clinical outcomes, underscoring the need for shared learning and systematic evaluation to strengthen primary care–based social needs programs.
A systematic review examined program-level processes that may influence the implementation of primary care-based social needs screening and intervention programs. The review found that programs focusing on a smaller, targeted population were more likely to screen and provide interventions to patients.
The findings suggest that healthcare systems could benefit from knowledge sharing and systematic evaluations to achieve better success in social needs screening and intervention programs. The review is published in Annals of Internal Medicine.
Researchers from Advocate Aurora Research Institute at Advocate Health in Milwaukee, Wisconsin reviewed 23 studies published between January 2015 to April 2025 that evaluated US-based programs using structured tools to screen adult patients for at least one of three social needs measures (food insecurity, transportation, and housing insecurity) followed by an intervention to address the identified needs in a primary care setting.
Studies were categorized by the patient populations eligible for screening: targeted or general. Targeted studies defined their eligible population by clinical condition, health care use, or insurance, whereas general studies included all patients.
Study Results
- The review found that screening rates ranged widely, from 2% to 91%.
- Among targeted populations, screening rates ranged from 38.3% to 90.9%.
- Among studies screening the general population, the percentage of patients screened ranged from 32% to 57%.
- In the four studies with the highest percentage of screened patients, all 4 received additional staff to assist the clinic with the screening process.
- The percentage of patients reporting at least one social need ranged between 10% and 100% across 13 studies.
- Programs reported wide variability in their ability to address unmet social needs, with 28% to 89% of patients receiving needed resources and effectively closing the social care loop.
- Intervention rates were generally higher among programs focusing on targeted populations compared to general populations.
- Few studies reported clinical and health care use outcomes, and the findings were mixed.
The findings of this review emphasize that considerable gaps remain in our understanding of the factors required to successfully screen for social needs, address those needs, and improve health outcomes.
