Physicians screen patients for social needs: what happens next? Survey, analysis, and policy recommendations

June 30, 2022

One red stick figure in the center is connected to many blue stick figures. Increasingly, physicians are screening patients for social needs then connecting patients to local organizations that can provide the required services. 

In Michigan, the U.S. Centers for Medicare & Medicaid Services provided funding to policymakers to launch new projects and partnerships to encourage physicians to screen for social needs like food and housing insecurity. The state also supported pilots that connected patients to community-based partners to address those needs(1)CHRT provides backbone support to MI Community Care, which began as one of those initiatives.. COVID-19 may have also played a role. COVID reminded us about the connection between social advantages, like housing, white collar jobs, and cars, and health.

In this new brief, CHRT shares data from its 2021 Michigan Physician Survey, finding that:

  • The percent of Michigan primary care doctors who know where to refer patients for social needs has gone up. But there is still lots of room for improvement. 
  • Screening for social needs and knowing where to refer patients for social needs do not always go hand in hand.
    • For some social needs, such as social isolation and loneliness, more doctors screen patients than know where to refer them.
    • For other social needs, such as food and housing, more doctors know where to refer patients than screen. 

CHRT’s policy and practice advice: 

  • While some debate the value of screening patients for social needs in the absence of routine referrals, screening is a necessary first step toward addressing important social needs and the health disparities associated with them. 
  • To improve health and combat health disparities, we can provide Michigan physicians with the information and resources they need to refer patients for community support. But that alone won’t solve the problem. 
  • We need to change reimbursement models to fund community-based organizations that address social needs. The community-based organizations that receive these referrals are still rarely reimbursed by the medical community for their contributions to patient health. Reimbursement would improve community capacity to meet patient referrals.



1 CHRT provides backbone support to MI Community Care, which began as one of those initiatives.