Programs

Health Related Social Needs & Health Equity

Health Related Social Needs Program

Health Related Social Needs (HRSN) are significant drivers of health outcomes. We recognize the importance of addressing the psychosocial needs of individuals in addition to their medical needs. SI PPS provides funding to community-based organizations to expand their capacity to serve individuals with health related social needs. Utilizing a referral management platform funded by SI PPS, agencies assess individuals in the community for social need and make closed-loop referrals to social services and supports.

Each organization deploys care navigators and other staff to conduct in-person or telephonic outreach. Care navigators utilize customized workflows in the platform to collect demographic information, complete a standardized, proprietary HRSN assessment, identify health related social needs, and make appropriate closed-loop referrals from a directory of community agencies. Each organization can monitor outgoing referrals, report on referral outcomes, and document ongoing follow-up with each individual.