Health Related Social Needs

When a patient with diabetes misses their appointment because they couldn’t afford the bus fare, or when someone with hypertension skips medication to pay rent, we’re witnessing health related social needs in action. These aren’t edge cases—they represent a fundamental challenge reshaping how we think about health, healthcare and healthcare delivery.

Understanding health related social needs (HRSN) has become essential for anyone working at the intersection of healthcare and community well being. Whether you’re a care team member, policy maker, or community advocate, grasping how social and economic needs influence a person’s ability to achieve optimal health is no longer optional—it’s foundational.

In this guide, you’ll learn exactly what HRSN means, how it differs from broader social determinants, and what federal and state programs are doing to address these barriers. You’ll also discover practical approaches for screening, connecting people living with unmet needs to resources, and designing services that actually work.

Understanding health-related social needs and social drivers of health

Before diving into solutions, some clarification. The terminology in this space can get confusing fast, so let’s break it down.

Health-related social needs (HRSN) are individual-level, self-reported challenges that directly affect a person’s ability to achieve good health. Think of these as the concrete, day-to-day barriers someone faces: trouble paying rent, lack of access to nutritious food, unsafe housing conditions, or gaps in transportation to medical appointments.

Social determinants (or drivers) of health (SDOH), on the other hand, operate at the community and population level. These are the broader systemic factors—economic stability, education quality, healthcare access, neighborhood environments, and social contexts—that shape health across entire communities.

The distinction matters because interventions look different at each level. You can’t solve community-wide poverty through individual case management, and you can’t address someone’s immediate food insecurity through policy reform alone.

Major frameworks from the CDC and WHO typically organize SDOH into five domains:

• Economic stability: Employment, income, expenses, debt, medical bills

• Education access and quality: High school graduation, enrollment in higher education, literacy, language

• Healthcare access and quality: Health coverage, provider availability, provider linguistic and cultural competency

• Neighborhood and built environment: Housing quality, access to transportation, availability of healthy food, crime and violence

• Social and community context: Social integration, support systems, community engagement, discrimination

According to research from the National Institutes of Health, social factors account for an estimated 40-55% of overall health status. Some analyses suggest social and behavioral factors drive up to 80-90% of modifiable health outcomes—far outpacing the roughly 10-20% attributed to clinical care.

Key differences between SDOH and HRSN:

Aspect	SDOH (Social Determinants)	HRSN (Health-Related Social Needs)
Level	Population/community	Individual
Source	Systemic conditions	Self-reported needs
Examples	Neighborhood poverty rates, school quality	“I can’t afford my utility bills this month”
Interventions	Policy change, community investment	Care navigation, referrals, direct services
Measurement	Census data, indices (ADI, SDI, SVI)	Screening questionnaires at point of care

The impact of SDOH and HRSN on health outcomes across communities

Social determinants shape health long before anyone walks into a clinic—and continue affecting outcomes long after they leave. The zip code someone is born in often predicts their health trajectory more accurately than their genetic code.

Consider the stark reality: life expectancy can differ by 10-20 years between neighborhoods in the same city, sometimes even by crossing a street. These aren’t random variations. They track directly with differences in economic stability, housing quality, access to grocery stores with healthy food, and environmental exposures such as pollution.

How community-level factors affect health outcomes

Areas with high housing cost burdens and limited access to affordable and stable housing show consistently higher rates of chronic diseases like diabetes and hypertension. When families spend more than 30% of income on housing, less remains for nutritious food, medications, and preventive care.

Food deserts—neighborhoods without convenient access to fresh produce and healthy food options—correlate with elevated rates of obesity, diabetes, and cardiovascular disease. Research demonstrates that people living in these areas face barriers that compound over time, creating cycles of poor health outcomes that span generations.

Air quality matters too. Communities near industrial facilities or major highways experience higher rates of asthma, COPD exacerbations, and other respiratory conditions. These environmental exposures don’t distribute equally across populations—they disproportionately affect lower-income communities and communities of color, driving health disparities.

How individual HRSN creates immediate barriers

At the individual level, unmet HRSN create direct obstacles to receiving and benefiting from healthcare:

• Housing instability makes it nearly impossible to sleep deeply, store medications properly, maintain a consistent diet, or recover safely after hospitalization

• Lack of reliable transportation leads to missed appointments, delayed preventive services, and gaps in chronic disease management

• Food insecurity forces impossible choices between eating and buying medications

• Utility shutoffs can be life-threatening for people dependent on powered medical equipment or climate control for health conditions

A patient with diabetes who lacks food security can’t follow dietary recommendations. Someone without stable housing can’t prioritize their hypertension management when they’re worried about where they’ll sleep. These aren’t failures of willpower—they’re predictable consequences of unaddressed social needs.

The result? Higher rates of emergency department visits, avoidable hospitalizations, and poor health outcomes that drive up costs while leaving people sicker. Addressing these needs isn’t just humane—it’s essential for any health system aiming to improve outcomes and reduce spending.

Federal and state initiatives that address health related social needs

The U.S. healthcare system is increasingly recognizing that you can’t achieve better health outcomes without addressing the non medical factors that shape them. This recognition has translated into significant policy and program innovations over the past decade.

Federal and state governments are now testing and implementing models that integrate HRSN screening, referral, and services into routine healthcare delivery. The goal is straightforward: connect people to the resources they need so clinical interventions can actually work.

The role of CMS and federal programs

The Centers for Medicare and Medicaid Services (CMS) Innovation Center has been testing payment and care models that require healthcare organizations to screen for HRSN and link patients to community resources. These accountable care models, launched after 2016, incentivize providers to look beyond clinical walls.

Medicare and Medicaid programs increasingly recognize that sustainable improvements in health require addressing underlying social factors. CMS guidance now allows states significant flexibility in how they approach HRSN, including options to cover evidence-based services for eligible populations.

The Children’s Health Insurance Program and Medicaid together serve over 90 million Americans—populations that often face higher rates of housing instability, food insecurity, and transportation barriers. Addressing HRSN within these programs has potential to significantly reduce health inequities and improve outcomes at scale.

State innovation through Medicaid

Several states have become leaders in using Medicaid flexibility to address HRSN. Through Section 1115 demonstration waivers, states can test approaches that go beyond traditional medical services. In California, CalAIM's Enhanced Care Management (ECM) and Community Supports (CS) programs offer targeted support:

• Housing supports: Assistance with deposits, short-term rental assistance, housing navigation

• Nutrition services: Medically tailored meals, produce prescriptions, nutrition education

• Transportation: Non-emergency medical transportation and access to essential services

• Utility assistance: Support for maintaining essential services like heat and electricity

• Community-based services: Navigation, care coordination, and linkages to human services

These programs aim to reduce avoidable hospital use, improve patient experience, and address health disparities by making social supports part of routine care delivery.

Examples of Medicaid 1115 waivers

A Section 1115 demonstration waiver allows states to test innovative approaches not typically covered under standard Medicaid rules. Think of it as a sandbox for policy innovation—states propose experiments, the federal government approves them, and both sides learn what works.

Washington State has been a national leader in this space. Their demonstration waiver (often called MTP 2.0) includes authority to pay for services addressing food insecurity, housing instability, and transportation barriers. The state has worked extensively with community based organizations and subject matter experts to design these benefits.

Many states are targeting go-live dates for new HRSN benefits between 2024-2026, with housing-related supports and medically tailored meals among the most common initial offerings.

Legislative directives and feasibility studies for expanding HRSN coverage

State legislatures increasingly pass bills directing Medicaid agencies to study and expand HRSN services. These legislative actions typically require:

• Feasibility studies examining which services offer the greatest potential health impact

• Stakeholder engagement with community members, providers, and advocacy organizations

• Formal reports evaluating the costs, benefits, and implementation requirements

• Timelines for federal waiver submissions and program launches

Laws enacted in 2023 and 2024 in several states have directed agencies to examine adding services like utility assistance, enhanced transportation benefits, and supports for people experiencing interpersonal violence. These studies often focus initially on high-need areas like housing and nutrition, where evidence of health impact is strongest.

Person-centered care and practical examples of addressing HRSN

Policy frameworks matter, but the real work happens in individual encounters between people with unmet needs and the care teams trying to help them. Person-centered care integrates medical treatment with attention to an individual’s specific health related social needs.

A day in the life: Marcus’s story

Marcus is 52 years old with poorly controlled Type 2 diabetes. His hemoglobin A1C has been above 10% for the past year despite multiple medication adjustments. His care team was frustrated—until they started asking different questions.

During an HRSN screening, Marcus revealed he’d been staying with different friends since losing his apartment six months ago. He couldn’t refrigerate his insulin consistently. He often skipped meals or relied on fast food because he didn’t have a kitchen. And he’d missed his last three appointments because he couldn’t afford Uber and the bus route required two transfers.

Once the care team understood Marcus’s situation, everything changed:

1. A care navigator connected him to a housing assistance program that helped secure stable housing within six weeks

2. The team arranged reliable transportation to his appointments through a Medicaid transportation benefit

3. A community health worker linked him to a food bank with diabetic-friendly options and helped him enroll in SNAP benefits

4. Weekly check-in calls ensured he was taking medications and attending follow-ups

Three months later, Marcus’s A1C dropped to 7.8%. He hadn’t needed any emergency room visits. The intervention that worked wasn’t a new medication—it was addressing the HRSN that made medication adherence impossible.

How care teams collaborate on HRSN

Effective HRSN interventions require collaboration across roles:

• Primary care providers identify clinical red flags that may signal underlying social needs

• Nurses, medical assistants or community health workers often conduct initial HRSN screening during intake

• Social workers assess complex situations and develop intervention plans

• Community health workers provide culturally responsive outreach and navigation

• Care navigators (often community health workers) coordinate referrals and ensure follow-through

The goal isn’t to make healthcare providers into social workers. It’s to build teams where clinical and social expertise work together, each contributing what they do best.

Screening for HRSN and connecting to community resources

Standardized HRSN screening transforms vague concerns into actionable data. Most screening tools assess core domains:

• Housing: Stability, quality, affordability, safety concerns

• Food: Access to enough food, ability to afford nutritious food

• Utilities: Risk of shutoffs, ability to pay bills

• Transportation: Access to reliable transportation for medical appointments

• Safety: Exposure to interpersonal violence or unsafe environments

• Social support: Isolation, availability of help in emergencies

Screening typically happens at intake visits, annual check-ups, hospital discharge, or during care transitions. Results get documented in electronic health records so the entire care team can see and act on identified needs.

The screening-to-resolution workflow:

1. Screen: Use validated questions to identify needs across key domains

2. Review: Care navigator or social worker reviews positive screens

3. Prioritize: Address urgent needs first (safety, immediate housing crisis)

4. Refer: Match patient to specific local resources (food bank, rental assistance, ride program)

5. Follow up (close the loop): Confirm services were received; address barriers to completion

The difference between effective and ineffective HRSN programs often comes down to that final step. Without structured follow-up—phone calls, home visits, text messages—many referrals never convert to actual services received.

The importance of trust, relationships, and longitudinal support

One-time interventions rarely solve complex health related social needs. People facing housing instability, chronic diseases, and limited income need sustained support over months or years.

The Camden Coalition, a national leader in complex care, has demonstrated that relationship-based models significantly outperform transactional approaches. Their longitudinal care model emphasizes:

• Consistency: Patients work with the same team members over time

• Patience: Trust builds gradually through repeated positive interactions

• Flexibility: Care plans adapt as circumstances change

• Respect: Patients drive priorities; teams provide support and options

Motivational interviewing by the provider enables them to meet the patient where they are at in the journey towards behavior modification to healthier habits. When a patient knows their care navigator will still be there next month—and the month after—they’re more likely to share difficult information, accept help, and engage with services.

Consider Maria, a 68-year-old woman with heart failure and depression who had been hospitalized four times in one year. Previous discharge planners had given her lists of resources that she never contacted. When a community health worker began visiting her weekly, building a relationship over three months, Maria finally revealed she’d been sending most of her Social Security check to her daughter’s family and couldn’t afford medications.

The relationship created space for truth. The truth made effective intervention possible.

Designing and implementing effective HRSN services

Whether you’re launching an HRSN program within a health system or expanding services through Medicaid, certain components predict success:

Essential program elements:

• Clear goals: Define what you’re trying to achieve (reduced hospitalizations, improved chronic disease control, better patient experience)

• Standardized screening: Use validated tools consistently across settings

• Strong community partnerships: Build relationships with food banks, housing organizations, transportation providers, legal aid groups

• Sustainable funding: Align reimbursement with services through Medicaid benefits, value-based contracts, or grants

• Continuous evaluation: Track which needs are most common, which referrals complete, and how interventions affect outcomes

Building effective partnerships:

Health systems cannot address HRSN alone. Effective programs require deep collaboration with community based organizations that have expertise, community trust, and service delivery capacity. This means:

Partner Type	Role in HRSN Services
Food banks and nutrition programs	Provide food assistance, medically tailored meals
Housing organizations	Navigate rental assistance, housing placement
Transportation providers	Deliver rides to appointments and essential services
Legal aid	Address barriers like evictions, benefits denials
Community health workers	Provide culturally responsive outreach and navigation, often with lived experience

Data and evaluation:

Programs should track key metrics including:

• Screening completion rates

• Prevalence of specific needs (housing, food, transportation)

• Referral completion rates (closed-loop referrals)

• Patient-reported outcomes

• Healthcare utilization (ED visits, hospitalizations)

• Cost savings

Privacy, consent, and equity:

HRSN services must be voluntary and non-stigmatizing. Patients should understand what information is collected, how it’s used, and who can access it. Programs should actively seek input from community members affected by the needs being addressed—not just design services for them, but with them. This enables cultural sensitivity.

Future directions and opportunities for innovation

The HRSN field is evolving rapidly. Several trends will shape the next five years:

Digital tools and closed-loop referrals:

Platforms that track whether services were actually delivered—not just referred—are becoming standard. These closed-loop referral systems create accountability and enable evaluation. Health information exchanges increasingly include social service data, allowing better coordination across departments and organizations.

Policy expansion:

Recent federal and state policy changes encourage investment in:

• Housing supports, including HRSN housing benefits like deposits and short-term rent assistance

• Nutrition interventions like medically tailored meals and produce prescriptions

• Expanded transportation benefits beyond traditional medical appointments

• Expanding access to benefits navigation and enrollment assistance

Regional coordination:

Community needs assessments provide information on population needs that guide healthcare and community organizations in providing targeted intervention and measuring improvements. Community information exchanges and regional health hubs are emerging as models for integrating medical, behavioral, and social data across organizations. These collaborative structures can reduce duplication, improve handoffs, and create more seamless experiences for people navigating multiple systems.

Research priorities:

The field needs better evidence on:

• Which HRSN interventions offer the greatest health impact and cost savings

• How to scale effective programs equitably across urban, rural, and frontier communities

• What workforce models best support sustainable HRSN services

• How to measure long-term outcomes from social interventions

Resources, partnerships, and ways to engage

Addressing health related social needs requires collective action. No single organization can solve these challenges alone—but every organization can contribute.

Where to find more information:

• CMS resources: Federal guidance on HRSN screening, Medicaid flexibility, and innovation models

• State Medicaid websites: Information on local 1115 waivers and HRSN benefits

• National toolkits: Screening protocols, referral workflows, and implementation guides from organizations like NACHC and the National Academy for State Health Policy

• Training centers: Programs focused on complex care, community health worker certification, and care navigation

How organizations can get involved:

• Join state-level advisory groups shaping HRSN policy and program design

• Participate in stakeholder meetings convened by Medicaid agencies

• Sign up for newsletters from state health departments and innovation centers

• Contribute data, stories, and lessons learned to learning collaboratives

• Partner with community based organizations already doing this work

The role of lived experience:

People who have experienced housing instability, food insecurity, and other HRSN understand what works and what doesn’t in ways that data alone cannot capture. Their voices should inform program design, evaluation, and continuous improvement, and should always be included.

Share real-world experiences from patients and front-line staff. These stories help raise awareness, refine HRSN programs and build the political will for sustained investment.

Health related social needs aren’t peripheral to healthcare—they’re central to whether healthcare works. The evidence is clear: addressing housing, food, transportation, and other social factors can improve outcomes, reduce costs, and advance health equity.

The infrastructure is being built. Federal and state programs are creating new pathways to fund and deliver HRSN services. Community based organizations are ready to partner. Care teams are learning to screen and refer.

What’s needed now is participation. If you work in healthcare, social services, policy, or community advocacy, there’s a role for you in building systems that address HRSN. Start by learning what’s happening in your state. Connect with organizations already doing this work. Advocate for investment in what we know matters.