Patient X arrives at a clinic for a routine health check-up. Upon check-in, they are asked to complete intake forms regarding family history, medication use, and insurance. However, the paperwork also includes a 10-item assessment that addresses five core domains: housing instability, food insecurity, transportation problems, utility difficulties, and interpersonal safety.
These questions are brief and straightforward – yet answering them is anything but simple.
Health-Related Social Needs & the Screening Process
Social determinants of health (SDOH) are the nonmedical, environmental, and socioeconomic conditions in which people are “born, grow, live, play, and age.” Accounting for roughly 30% to 55% of health outcomes, SDOH have garnered widespread attention across healthcare systems, prompting providers and policymakers to look beyond a patient’s direct medical needs and consider the social risk factors that influence health. At the individual level, health-related social needs (HRSN) emerged as a concept from the broader SDOH framework, becoming increasingly defined and operationalized in the late 2010s and early 2020s as direct, measurable drivers of health within clinical environments. In 2023, the Joint Commission required health systems to screen for specific HRSNs, including access to transportation, difficulty paying for prescriptions or medical bills, education and literacy, food insecurity, and housing instability; and in 2024, the Centers for Medicare & Medicaid Services (CMS) required HRSN screening in acute care hospitals.
As part of the HRSN screening process, patients must complete a set of standardized questions, either through self-administered paperwork or staff-administered questionnaires by medical assistants, nurses, social workers, or patient navigators. Patients who screen positive may be referred to community health workers to connect with community-based organizations (CBOs) and services that assist with Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment, and/or food and housing assistance.
At face value, the screening process appears straightforward: ask, identify, refer. But the reality of HRSN assessment is far more complex than these streamlined workflows suggest, revealing the hidden – and often unspoken – costs of screening.
Let’s return to Patient X. As they complete their intake forms, feelings of shame and apprehension begin to surface, as they question whether they can trust their provider with such personal information.
Although research indicates that HRSN screening is generally well accepted among patients across diverse healthcare settings, high acceptability does not necessarily translate into the immediate relief of social and economic difficulties. Broaddus-Shea et al’s multi-phase Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study found that questions related to food insecurity, housing instability, or financial hardship carry significant emotional weight, especially within clinical settings where patients may already feel vulnerable. Concerns about privacy, mistrust in the provider, fears of reporting to child protective services, and past experiences of healthcare discrimination may also discourage patients from fully disclosing their circumstances. patients from fully disclosing their circumstances.
When a nurse reviews Patient X’s forms, they find that Patient X screened positive for food insecurity. The nurse offers assistance, providing a free bag of groceries, information about a local food bank, and the number for the Department of Transitional Assistance (DTA) to apply for SNAP. When Patient X contacts the DTA, they are abruptly disconnected from the call before a caseworker can answer. Despite several attempts to reach the DTA, Patient X was unable to connect with a caseworker and therefore unable to apply for SNAP benefits. Since the health clinic is short-staffed and overburdened with high patient volume, they do not have the capacity to follow up with Patient X to determine whether resources were received.
The “Bridge to Nowhere”
When referrals fail to connect patients with the necessary support, the emotional weight associated with screening heightens – leading some to describe this process as a“never-ending circle”of repeatedly disclosing unmet needs without receiving meaningful assistance. This so-called “bridge to nowhere” remains a critical issue in HRSN assessment, where screening tools designed to identify and address disparities unintentionally reinforce them instead.
Unfortunately, the story of Patient X is far from unique.
A qualitative improvement initiative in the adult emergency department of an urban safety-net hospital implemented a social needs screening and referral program and found that 27.0% of patients screened reported at least one unmet social need. Of those who were screened, 74.8% requested assistance, but only 24.5% recalled receiving resource guides. In a separate cross-sectional survey assessing the effectiveness of social resource referrals among caregivers of pediatric inpatients, more than half of the referrals (61.2%) made for families did not result in a successful resource connection.
Instances of failed referrals persist across a diverse range of healthcare settings, with occurrences becoming increasingly prevalent due to the immense and growing political and economic strain on the nation’s social safety net infrastructure. Although the importance of HRSNs have gained greater recognition within healthcare systems, recent policy shifts have constrained system capacity to address them.
In March of 2025, CMS published a Center for Medicaid and Children’s Health Insurance Program (CHIP) bulletin rescinding Biden’s policies that encouraged the use of Medicaid authorities, including Section 1115 demonstration waivers, to address HRSNs among Medicaid enrollees. The previous framework outlined pathways for states to cover HRSN services through 1115 waivers, but under this recission, CMS requests that new or expanded HRSN authorities be evaluated on a case-by-case basis. As of June 2026, no new HRSN-related 1115 waivers have been approved by CMS.
Simultaneously, the social safety net programs healthcare’s referral pathways depend upon have been uprooted by the “One Big Beautiful Bill Act” (OBBA, or H.R. 1), resulting in significant funding cuts to Medicaid, SNAP, and other support programs for low-income households. Over the next decade, the Commonwealth Fund predicts that the combined losses from proposed Medicaid and SNAP cuts could reach $1.1 trillion, including a $95 billion loss of federal funding in 2026.
Beyond the federal level, charitable food systems (e.g., food banks) are under significant pressure to fulfill increased demand despite limited capacity. Food banks are pivotal in providing individuals and families with meals, but these organizations alone cannot resolve food insecurity, especially when they are overstretched themselves. SNAP provides nine meals for every one meal a food bank provides, underscoring the need for a robust federal framework that supports the structural and financial well-being of public assistance programs.
The ripple effects of such institutional erosion are felt most by the very patients HRSN screening is intended to support. As the accessibility and availability of safety net programs diminish, patients with unmet needs may be caught in a persistent feedback loop of repeated screening without a path for intervention. The downstream impacts may exacerbate existing inequities while deepening patient distrust in both our healthcare system and the nation’s social safety net programs.
As healthcare systems across the country have made historical progress in defining and integrating social risk factors into clinical care, this moment of political and economic uncertainty should not define the future of HRSN. The screening infrastructure exists, but the challenge now is to ensure assessment is paired with sustainable, actionable, and patient-centered care.
So how do we, as public health practitioners, clinicians, researchers, and policymakers, address these shortcomings to ensure that those most at risk have equitable access to support amid a crumbling social safety net? Despite the fairly bleak reality of our current socioeconomic situation, the argument can be made from a medical ethics standpoint that healthcare efforts to provide social care in addressing patients’ HRSNs remain morally permissible, if not required.
A Path Forward: Redefining the Future of Health-Related Social Needs in Healthcare
Building Trust between Patients and our Healthcare Systems
“Trust is earned, not given,” is a phrase rooted in reliability, integrity, and honesty. Within our healthcare systems, these values are foundational to all aspects of care, from preventive health to targeted interventions. While it is critical that patients feel safe and comfortable throughout the screening and referral process, it is also important to recognize that trust within healthcare is not one-dimensional. Instilling trust between providers and their patient population requires analyzing the roots of distrust, such as systemic discrimination and lack of transparency. Research indicates that experiences of healthcare-based discrimination were associated with low patient trust in providers, underscoring the critical need for structural interventions that mitigate harmful practices. Trauma-informed care and clear communication about the purpose of HRSN screening are key opportunities to build and strengthen patient trust both within and beyond the provider. When designed and implemented in a manner that preserves patient dignity and autonomy, HRSN screening can be one mechanism in which healthcare systems begin to earn patient trust. By recognizing and addressing the faults in our system, we can progress towards a future that fully centers patients’ well-being while holding healthcare systems to a high degree of accountability.
Investing in an Interconnected Channel: Healthcare Workers, CBOs, & State Agencies
HRSN screening cannot function without sustained investments in healthcare workers, local CBOs, and state agencies.
Conversations around HRSNs require time, trust, and empathy. However, healthcare workers are often burdened with administrative tasks, workforce constraints (e.g., high patient volume and staffing shortages), and emotional strain. These barriers make it difficult to address HRSNs thoroughly and engage fully with patients throughout the screening process. Creating the conditions for providers to establish strong relationships with their patients requires integrating practices that support providers themselves. Integrated care teams and closed-loop referral systems are two approaches that can increase provider capacity and allow for more meaningful interactions between patients and providers.
Supporting providers also means prioritizing and building relationships with local CBOs. Intentional and sustained collaborations between providers, CBOs, community educators, and other key stakeholders are necessary to address the institutional and organizational barriers to care. Because CBOs often have longstanding relationships with the communities they serve, they are seen as “trusted messengers” among community members to synthesize and disseminate complex health-related topics in an accessible manner. Thus, CBOs are uniquely positioned to meet individuals and families where they are and connect them with culturally relevant resources and support. A strong network of partners lays the foundation for collective trust and creates opportunities to expand community-engaged research, practice, and action.
Effectively connecting patients with the support they need also requires investing in state agencies that administer the social safety net programs to which they are referred. Ensuring that programs such as Medicaid and SNAP have robust benefits and straightforward, accessible enrollment processes is essential to preserving the integrity of the screening process, so that the referral leads to a helpful destination. Without robust referral pathways, screening risks becoming an extractive tool that elicits personal information from a patient rather than serving as a method for intervention and support.
To sustain the screening infrastructure, a growing body of research highlights the need to invest in the caseworker workforce. Caseworkers work closely with individuals and families to connect them with various forms of assistance and social services, serving as a bridge between providers, patients, and social safety net programs. In recent months, however, caseworkers at the Massachusetts Department of Transitional Assistance have been under immense strain to fulfill increased community needs, receiving an average of 20,000 calls a day, answered by 645 SNAP caseworkers. Despite the state’s hiring efforts, the Massachusetts Law Reform Institute estimates that more than 200 additional caseworkers are needed to support the state’s residents. This pressure is likely to intensify as H.R.1 guidelines impose stricter SNAP work requirements, expanding them to individuals ages 18 – 64 years old to document work, volunteer, or training hours to maintain benefiting hours to maintain benefits.
These work requirements add yet another layer of administrative work that caseworkers must address in addition to assessing eligibility and assisting applicants’ complete enrollment paperwork. The DTA is simply one example of an overstretched workforce; similar pressures can be seen across energy assistance, housing assistance, and early childhood services where funding constraints and increased demands make it increasingly difficult to support community needs. The collapse of these programs underscores the need to prioritize, invest in, and sustain the administrative backbone of our social safety nets to ensure they remain available and accessible to communities in need.
Currently, many healthcare workers, CBOs, and state agencies are underfunded and under-resourced despite being the pillars that support community health and well-being. Coordination across sectors and systems is therefore critical to building a resilient network that both patients and referral pathways can rely on.
The Power of Advocacy & Storytelling
Behind the statistics and screening metrics are individuals like Patient X, whose disclosure of HRSNs represents far more than a checked box on an intake form. While screening data highlight the prevalence of unmet needs, patient narratives contextualize metrics that data alone cannot explain. Addressing the limitations of HRSN screening requires pairing data collection with advocacy efforts that center the lived experiences of affected communities. Integrating patient stories into HRSN initiatives can help healthcare systems better understand the barriers, priorities, and circumstances that drive health outcomes.
To promote storytelling initiatives across communities, healthcare professionals can refer to the Communication Infrastructure Theory (CIT): a framework that analyzes the role of storytelling in maintaining and advancing community health. The CIT suggests that providers can leverage an existing network of residents, CBOs, and local media to facilitate programming initiatives to address community needs. By weaving patient narratives into program design and evaluation, healthcare systems can develop responsive screening processes that reflect patient stories rather than simply relying on data alone. HRSN screening provides a snapshot of a moment in time, but stories paint the picture of the human experience. Together, these insights can drive actionable change within policy and healthcare.
Concluding Thoughts
Healthcare functions within an ecosystem of policy, community partnerships, and sustained investments in social services. In a moment of heightened political and social tensions, it is important – now more than ever – to build community capacity and prioritize the needs of those most vulnerable. HRSN screening was designed to identify and address social drivers of health, but achieving this goal requires understanding that this process is multifaceted, complex, and ever-changing. When our systems fall apart, individuals and families suffer the consequences. Protecting and investing in SNAP, Medicaid, and the overstretched caseworker workforce are not separate from clinical care. Rather, they are what keeps screening from becoming a bridge to nowhere.