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Screening for Social Needs in Health Care Systems: A Quality Improvement Framework and Two Case Studies
Megan Cahn1, Shivonne Laird2, Terrisca Des Jardins3
1Department of Population Health, Legacy Research Institute, Portland, Oregon, USA.
Population Health Management
|May 29, 2026
Summary
Integrating social care into healthcare addresses health-related social needs (HRSN). A Learning and Action Network (LAN) demonstrated improved HRSN screening rates through collaborative quality improvement strategies.
Area of Science:
- Public Health
- Health Services Research
- Social Determinants of Health
Background:
- Social determinants of health (SDOH) and health-related social needs (HRSN) significantly impact health outcomes.
- Healthcare systems increasingly integrate social care to address non-clinical factors and advance health equity.
- Integrating social and healthcare requires complex coordination among multiple stakeholders.
Purpose of the Study:
- To describe the framework and outcomes of a Learning and Action Network (LAN) focused on integrating social care into healthcare.
- To share practical examples and learnings from integrated delivery networks (IDNs) implementing HRSN screening strategies.
- To highlight successes and challenges in improving HRSN screening rates within healthcare settings.
Main Methods:
- A quality improvement framework was employed, utilizing a three-part data review process.
- Plan-Do-Study-Act (PDSA) cycles were used to test and refine social care integration strategies.
- Three integrated delivery networks (IDNs) participated in the LAN, sharing learnings and results.
Main Results:
- Participating IDNs achieved significant improvements in health-related social needs (HRSN) screening rates.
- The LAN facilitated collaborative learning and the sharing of practical social care integration strategies.
- Key successes and challenges encountered during the implementation of HRSN screening were documented.
Conclusions:
- Intentional engagement with healthcare leadership and community partners is crucial for successful social care integration.
- Close monitoring of implementation and evaluation of outcomes are essential for achieving health equity.
- The LAN model provides a valuable framework for improving HRSN screening and advancing health equity in healthcare systems.
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