Short-term outcomes:Screening and Referral for Health and Social Services
Advancements in interoperability and data sharing can facilitate screening and referral for health-related social needs, such as food insecurity or lack of transportation. However, screening and referral alone are not enough. There must be high-quality, accessible, and culturally competent services in the community to meet these needs, along with supports to help individuals access them.
Screening and Referral Examples
Explore the sections below to learn about screening and referral to address unmet health-related social needs for older adults and caregivers, and the importance of the availability of these services.
Screening
Screening is a critical first step that identifies unmet needs. From there, a plan to address the most relevant needs can be developed.
Activities to encourage screening for health-related social needs have been around for many years, but it is difficult to track the full extent to which health care providers are conducting such screenings and how individuals with needs are connected to services. Z codes, for example, are a set of International Classification of Diseases codes (ICD-10) established in 2015 that reflect a patient’s social and economic circumstances, which can reflect health-related social needs. However, Z codes need wider, more consistent use by providers. Given the growing evidence that adequately addressing social needs can have positive impacts on health outcomes, policymakers and health plans are exploring ways to encourage the screening of health-related social needs as a first step. Below are three examples of screening-related policies; additional examples can be found on the Policy page.
Call to Action!
Want to learn how you can help make a difference? Consider the following activities and ideas.
Funders
- Invest in culturally and linguistically inclusive interventions that improve screening and referral, and data exchange that promotes better, more equitable and coordinated care for older adults.
- Explore seed funding for technologies that facilitate screening and referral for older adults, particularly those who experience barriers to in-person appointments.
- Close gaps in available community supports regarding the availability and cultural competency of services (e.g., food, housing, transportation), with a focus on reaching marginalized and underserved communities.
Policymakers
- Develop reimbursement models that prioritize use of culturally and linguistically appropriate screening, referral, and services to address health-related social needs.
- Prioritize policies that elevate screening and referral for older Black, Indigenous, and people of color.
- Seek the development of age-friendly communities that focus on improving older adult outcomes by leveraging intersections between health and social services.
- Develop and evaluate policies with attention to the frequent overlap between different health-related social needs (e.g., transportation and socialization), and avoid creating or reinforcing artificial silos that neglect these overlaps.
Advocates
- Increase awareness about the importance of health and well-being screenings for older adults, with a focus on closing gaps in disparities across race, ethnicity, language, gender, socioeconomic status, and geography.
- Encourage investments that promote the availability and sustainability of social services in community settings.
- Seek better referral processes for those providing health and social services as a way to ensure that older adults receive whole-person, holistic care.