A framework for integrating health-related social needs education into electronic health record clinical pathways

Health-related social needs (HRSN) significantly influence patient outcomes, yet they are rarely integrated into point-of-care decision-making. We developed a process to embed HRSN-informed and HRSN-targeted care recommendations directly into three electronic health record-integrated high-use clinical pathways-cirrhosis, diabetes, and congestive heart failure-at a tertiary academic medical center and affiliated community hospitals. This pilot process leveraged literature review, community input, interdisciplinary collaboration, and targeted specialist feedback to produce concrete, actionable guidance for providers. Our approach can be adapted by other health systems to address social needs within established clinical workflows.