New Framework Facilitates Primary Care-Community Organization Partnerships to Screen for Social Determinants of Health

NEW YORK, NY—June 6, 2019—United Hospital Fund (UHF) today released a framework designed to help primary care providers screen their patients for social determinants of health and partner with community-based organizations (CBOs) that can respond to those needs.

A growing number of health care providers in New York are screening for social determinants and forging partnerships with social service organizations to address economic and social factors that affect health, such as substandard housing, food insecurity, and poverty. However, successfully screening patients for social needs, referring them to organizations that can provide needed services, and following up to determine outcomes, is all extremely complex. The framework and report provide guidance on selecting a screening tool, developing a realistic workflow, identifying appropriate CBO partners, and building and maintaining those new relationships. 

In this year-long project, UHF worked with two federally qualified health centers to understand and document the process of screening for social needs in primary care, developing partnerships with CBOs in their community to design and implement processes to facilitate referrals and follow-up on patients referred for assistance with those needs.

The project was supported by the New York City Population Health Improvement Program (NYC-PHIP), with funding from the New York State Department of Health. The resulting report, Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health, explores how the processes can be developed and describes the challenges to achieving scale and sustaining these efforts.

“Screening for social determinants in primary care is still a comparatively new thing” said Gregory C. Burke, director of UHF’s Innovation Strategies initiative and a co-author of the report. “Though the steps for a referral may appear simple, successfully executing these steps is actually quite complicated. In this report, we explored some of that complexity, and how these referral processes work in the real world.”

The report also notes four challenges to successful and sustainable partnerships between primary care providers and community-based organizations:
•    Developing standardized information technology systems, currently lacking, that can track social needs and work for both clinical practices and community-based organizations. 
•    Ensuring that community organizations, particularly smaller ones with fixed funding, can manage the increased demand for services.
•    Instituting payment systems that generate the investments needed to respond to the type and volume of social needs that may be identified through screening.
•    Evaluating the effectiveness of these new programs, from both the patients’ perspective and at the population level, in identifying and reducing the many social needs that lead to disparities in care and outcomes.

“The health care and social services sectors share the same goal of improving the well-being of our patients.  By collaborating and coordinating our efforts, we can make a more meaningful difference the lives of disadvantaged populations,” said UHF president Anthony Shih MD, MPH. “At United Hospital Fund, we are committed to advancing the field of clinical-community partnerships to address the broader determinants of health.” 

The report was co-authored by Kristina Ramos-Callan, UHF program manager, and Chad Shearer, vice-president for policy and director of the Medicaid Institute at UHF. It can be downloaded from the UHF website here. 
About United Hospital Fund
United Hospital Fund works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care. For more on our initiatives and programs please visit our website at and follow us on Twitter

About the New York City Population Health Improvement Program
In January 2015, the New York City Department of Health and Mental Hygiene joined in partnership with the Fund for Public Health in New York, the United Hospital Fund and the New York Academy of Medicine to launch the New York City Population Health Improvement Program (PHIP). The NYC PHIP is one of 11 PHIPs created around the state to achieve inclusive health planning at the regional and local level. The PHIP promotes health equity as well as the “Triple Aim” of better care, lower health care costs and better health outcomes for New Yorkers.


June 6, 2019
Focus Area
Clinical-Community Partnerships
Innovation Strategies