Physicians’ knowledge of where to refer patients for social needs has increased, but opportunities for growth remain

June 30, 2022

A growing strategy to improve individuals’ health and well-being has been to address their social needs—food, housing, transportation, employment, and more—often referred to as social determinants of health.

Increasingly, physicians are being offered incentives that encourage them to screen patients for social needs and connect them to community-based organizations for services. However, community-based organizations are still rarely compensated by the medical community for their contributions to patient health.

In Michigan, there has been considerable momentum around social determinants of health in recent years, with support from the U.S. Centers for Medicare and Medicaid Services (CMS) that launched new projects and partnerships to incentivize social service screenings and referrals. The COVID-19 pandemic has also served as a catalyst, as it increased awareness of the connection between social needs and health.

In a new brief that analyzes data from the 2021 Michigan Physician Survey, CHRT discusses how physicians’ knowledge of where to refer patients for social needs has changed since the start of the COVID-19 pandemic and highlights gaps between physicians’ routine screening and referral ability for social needs.

 Key findings from our survey and study:

  • The percentage of Michigan primary care physicians who know where to refer patients for social needs, such as food or housing insecurity, has increased since 2018—but there’s still lots of room for improvement. 
  • Physicians are less likely to know where to refer patients for social isolation, unemployment, and lack of health literacy.
  • Routine screening for social needs and knowledge of where to refer patients for social needs do not always go hand in hand.
    • For some social needs, such as food and housing insecurity, screening rates lagged behind knowledge of where to refer patients.
    • For other social needs, such as social isolation and loneliness, more physicians reported screening patients than knowing where to refer them.


  • While some debate the value of screening patients for social needs in the absence of 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—that’s how we address community capacity to meet referrals.