Beyond Screening: Addressing Social Challenges After the Questions Are Asked

Social determinants of health (SDOH) screening tools have been prioritized in emerging healthcare delivery models aimed at transforming traditional care delivery and reimbursing a broader bench of supportive services. However, with the shift in priorities that often accompanies a new federal administration, changes are already in the works for SDOH. 

Currently, the Trump administration has rescinded the Biden administration’s guidance on the creation and administration of SDOH and health-related social needs (HRSN) services for Medicaid and Children’s Health Insurance Program (CHIP), saying that approval for service requests that address HRSN/SDOH will be determined on a case-by-case basis moving forward. While some of the previous guidance for HRSN/SDOH screening remains unchanged, specifically for in-patient HRSN screening, additional time is needed to evaluate the overall impact on HRSN/SDOH screenings and services over this administration’s term. 

Given these new parameters, it’s important to make sure that SDOH screenings are more than a check-the-box maneuver. It’s imperative that healthcare leaders have a meaningful plan established for after these screenings take place — to follow through on what a patient shares and successfully address inequities for better health outcomes. What are the broader issues at play? What happens when healthcare organizations lack a standardized approach to follow through? And what does a new approach look like?

Challenges with current screening 

Tools such as the AHC Screening, developed to address critical gaps between clinical care and community services in our healthcare system, are edging toward standardization but remain inconsistent in use. Screening is considered a best practice but not yet uniformly adopted by providers and organizations across the continuum of care. There are a few different reasons for this today. 

First, many healthcare organizations default to readily available tools that meet requirements without assessing their alignment with specific needs. Clinicians providing direct patient care are already stretched thin. It’s unrealistic to expect them to take on additional manual data entry with poor integration or limited data exchange to external services that process screening results outside the health system, not to mention asking them to access different systems to conduct screenings or see results because screening tools often aren’t integrated into the technology platforms and EHRs the providers are accustomed to using.

Additionally, when collected data goes unused, it not only leaves identified challenges unaddressed — widening gaps in care — but also erodes patient trust, as they share deeply personal information with the expectation that it will inform their care. A patient’s willingness to participate in a screening and stay engaged is built around trust. A study published in The American Journal of Managed Care reported a 31.4% decline in patient trust between April 2020 to January 2024, which makes supporting the clinical relationship even more of a priority for new policy implementation. 

Screening is not enough

As we know, identifying challenges such as food insecurity or housing instability that can impact people’s lives doesn’t solve them. Yes, it’s a benefit to be made aware of them (“you can’t manage what you can’t measure”); however, many clinicians lack the resources and road maps to address these issues effectively. It’s a much broader issue. The fact is that screening tools are artifacts; their value depends on how they’re used, what happens after, and the systems supporting them.

As a sector, we need to move beyond measuring the process of screening to measuring the outcomes. SDOH challenges are rooted in systemic inequities in areas like food accessibility, education, and housing. No one is going to say: “Because I was screened, I was able to feed my family.” The step after the screening matters entirely, and payers and providers have an opportunity to build a better system here. Referrals alone aren’t enough; we need to connect individuals to actionable pathways and then measure the impact of those connections. Measuring outcomes takes time, but it matters. Screening is only the starting point, not the finish line. 

A new approach to SDOH

There is no question that screening for SDOH plays a significant role in how we deliver healthcare to communities, understanding that the current screening process is not yet a standard, but a best practice — and one that is being tested at a mercurial moment in our sector. There are ways we can realistically improve data collection and service delivery, starting with better understanding community health needs. However, the role of the provider in this process cannot be discounted. 

By measuring without offering solutions, we’re perpetuating reactivity and creating a system of injustice — for the provider who is already stretched thin and the patient who may be screened in a way that is haphazard without the follow-through to address their needs in full. Providers need to be equipped with the resources and time to meaningfully follow through with their patients who share SDOH needs and then to be able to synthesize the data they are receiving and see it applied toward better outcomes for their patients. 

SDOH screenings are a critical tool, but they are only the first step. The healthcare system must together rise to the challenge of addressing the root causes of inequities and create pathways for patients to access meaningful support in order for them to actually make a difference.

Photo Credit: Big Stock

Danielle Carter is CEO of Intrepid Ascent, bringing over 15 years of experience in global public health, healthcare, and community-based public health initiatives. Since joining the Intrepid team six years ago she has been instrumental in guiding the company’s growth, including deepening impact on Medicaid programs and community health transformation, centering services around the needs and experiences of the people they serve, and applying quality improvement and human-centered design methodology. With Carter’s leadership, Intrepid has strengthened its ability to implement programs at the intersection of healthcare and social services, using technology to connect partners and transform communities.

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