02 — Capability · BC-1860.50
Social Needs & Community Resources
Find the social needs, such as food, housing and transport, that stand between people and good health, connect them with community organizations that can help and close the loop on each referral. Corporate giving and community relations sit with communications.
- Social Determinants of Health
- SDOH
- Health-Related Social Needs
- Social Prescribing
In scope
- Social needs screening
- Community resource directory and closed-loop referrals
- Community health worker and navigator programs
- Community health needs assessment
Out of scope
- Corporate community relations and giving (see BC-480.40)
- Financial assistance and help with coverage applications (see BC-1810.50)
- Enrolling people in care management programs (see BC-1860.20)
Realized by · 2
- Oracle Health · Health Data Intelligencestrong via BC-1860.50.50
- HealthEdge · Wellframe Member Engagementstrong via BC-1860.50.20
Used in · 2
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 5
- BC-1860.50.10Social Needs ScreeningAsk patients and members about social needs with a standard set of questions, record the answers as structured data, and flag needs to the care team.
- BC-1860.50.20Community Resource DirectoryKeep a current directory of community services, their eligibility rules and capacity that staff and patients can search.
- BC-1860.50.30Closed-Loop Community ReferralsRefer people to community organizations and learn whether help was received, closing the loop with the referring team.
- BC-1860.50.40Community Health WorkersDeploy community health workers and lay navigators who meet people where they live and help them through care and social services.
- BC-1860.50.50Community Health Needs AssessmentAssess the health needs of the communities the organization serves on a set cycle, with public input, and publish a plan to meet them.