System Approaches to Social Determinants of Health Screening and Intervention

University of North Carolina Health aimed to increase screening both to inform patient care and to understand population level needs. Using existing infrastructure and governance, new workflows, and modifying responsibilities for existing population health employees, UNC Health developed and spread new processes for collecting and acting on social needs (food insecurity, financial resource strain, housing instability, and lack of reliable transportation). In the first year, the health system screened almost a quarter of a million patients for at least one social need in its primary care network. Sixteen hundred referrals have been placed to a new community health team to assist patients in meeting their social needs.