A community member, care coordinator, and community partner connect a screening form with food, housing, and transportation resources.

Social Needs Screening: A Readiness Checklist

BySherry Sayari, MPH
4 min read

A screening question is a kind of promise. When an intake form asks whether someone has worried about running out of food or losing their housing, the person answering reasonably expects that a yes will lead somewhere. If it doesn’t, the question has cost them time, privacy, and a little trust, and given nothing back.

This checklist is for the stretch before launch, when a clinic or program is deciding whether to add social needs questions. One rule sits behind every item: don’t turn on a question until each possible answer has a defined response, a named owner, and a current resource behind it. If a domain isn’t ready, it is better to hold that question back than to ask it and improvise.

Start with what a screen can and can’t do

CMS distinguishes social drivers of health, the broad conditions in a community, from health-related social needs, the specific needs affecting one person, such as unstable housing, limited food access, transportation barriers, utility needs, and safety concerns. A screen finds individual needs. It can’t change community conditions, although the pattern of answers over time can show where those conditions press hardest.

The CMS Accountable Health Communities Model was built around more than the question. It combined screening with referral, community navigation, and alignment between clinical and community services. That sequence makes a good readiness test.

For every domain

  • A written response for each answer. What happens after a yes, after a no, and after a skipped question.
  • A named owner. A care coordinator, community health worker, social worker, or navigator reviews the result and contacts the person, and someone is named to cover when that person is out.
  • A current resource. Eligibility, hours, service area, required documents, and wait times checked recently, with a date on the entry.
  • A way for partners to say they are full. A referral to an organization that can’t accept it adds a step for the person without moving them forward.
  • A plain answer for when nothing is available. An honest explanation serves the person better than a long list that leads nowhere.

Food

Availability is only one part of access. A store may be close by and still hard to reach without a car. Food may be on the shelf and unaffordable. A household may qualify for benefits and struggle to complete a renewal.

  • Resources cover cost, not only location: benefits, food pantries, and lower-cost options.
  • Someone can help with applications and renewals, or knows exactly where to send the person for that help.
  • Transportation to food sources is part of the plan.
  • The response accounts for storage and cooking limits, such as no working refrigerator.
  • People managing a health condition can be connected to foods that fit their needs, not just enough calories.

Housing

  • Questions about housing quality are kept separate from questions about losing housing, because the responses are different.
  • The team knows which local organizations handle rental assistance, eviction prevention, and shelter, and what each requires at intake.
  • Criteria for same-day escalation are written down, for example someone with no safe place to sleep tonight.
  • Staff can explain that a positive answer does not guarantee assistance.

Transportation

  • Staff know what ride options exist and how far ahead they must be booked.
  • The plan covers trips beyond medical visits where possible, such as pharmacy and grocery runs.
  • There is a fallback when a ride falls through: rescheduling without penalty, or a phone or video visit when that is clinically appropriate.

Utilities

  • The resource list includes local assistance programs, with notes on application periods and funding, which can change during the year.
  • A shutoff notice triggers a faster response than a general worry about bills.
  • Staff ask whether anyone in the home relies on medical equipment that needs power, since that changes the urgency.

Safety

  • A protocol is written with people trained in this area before the question goes live.
  • A trained contact is reachable whenever screening happens, so front-line staff are never left to decide alone.
  • The question is asked privately, not in front of companions unless the person chooses.
  • Rules for what is documented, and who can see it, are settled in advance.

How you ask

  • People hear why the questions are asked, how answers will be used, and that answering is optional. The CMS guide to the Accountable Health Communities screening tool notes that people may skip questions they would rather not answer.
  • Screening never happens at a public counter or within earshot of a waiting room.
  • Language is respectful and free of labels, and forms are short enough to finish.
  • Staff check what is already on file, and how recent it is, instead of asking the same questions at every visit.
  • People have a say in what kind of help they want and how they would like to be contacted.

After the referral

  • The team agrees on what follow-up means and gets consent for it.
  • Follow-up looks for barriers and closes the loop where possible, an approach CMS describes in its Enhancing Oncology Model guide to health-related social needs.
  • Only the information coordination requires is collected and shared.
  • Unmet needs are reviewed with community partners, because a missing resource is a capacity problem, not a staff performance problem.

When a domain isn’t ready

Phasing in is a legitimate choice. A program that launches with two domains it can answer well, and adds the rest as partnerships and protocols mature, keeps faith with the people it asks. The goal is a screen where every question has somewhere to go.

Sources

About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.

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