Understanding the often complex social and psychological needs of patients is critical to creating interventions that achieve better health and wellbeing. Every 3 months, we ask patients about their unmet social needs across 17 domains based on an assessment developed by Health Leads. We ask about needs such as for public benefits, insurance, housing, transportation, healthy eating and social engagement. We find the types of needs vary widely and therefore make it difficult to target the top few needs alone. To address this, we are developing strategies to target clusters of unmet social needs.

In addition, with this information in hand, the C4P clinical team can better understand the myriad of factors impacting their patient and provide more holistic care, connecting patients to the right social resources as needed.