Health Systems Must Prepare for the Operational Reality of Social Needs Screening

Since January 2024, Kentucky Medicaid has required SDOH screening not only in inpatient settings but across primary care clinics serving both adults and children. Simultaneously, the Centers for Medicare & Medicaid Services (CMS) has expanded expectations around health equity, patient engagement, and social needs tracking through its updated quality reporting programs.

These moves reflect a national shift in how health is conceptualized, and reimbursed. But they also impose logistical burdens on provider organizations. Screening uncovers needs, but without corresponding navigation infrastructure, referrals, and follow-up protocols, the data becomes a liability rather than an asset. According to a 2024 survey by Kaufman Hall, more than half of health systems reported that social needs screening programs generated insights they lacked the capacity to address operationally.

In this context, UK HealthCare’s use of public health students as structured support agents is not just innovative. It’s instructive. Rather than treating unmet needs as clinical footnotes, the system created an interdisciplinary workgroup, mapped referral pipelines, and embedded trainees into service coordination roles, all while collecting data to evaluate outcomes.

SDOH Implementation Requires More Than Referrals

Most health systems have invested in screening tools embedded in the EHR. But what happens after a patient indicates food insecurity or unstable housing? Too often, the result is a generic resource handout and little follow-up.

UK HealthCare moved beyond that transactional model by integrating students into the full referral lifecycle, from outreach and assessment to linkage and documentation. Some students received community health worker training, others supported data analysis and resource mapping, and several participated in qualitative research assessing coordination between hospitals and community-based organizations.

This model addressed two urgent needs simultaneously: helping the system manage rising referral volumes without overextending clinical staff, and offering students experiential learning grounded in real-world patient engagement.

It also surfaced a core operational truth: SDOH intervention is not a one-size-fits-all process. As one student noted, what worked for one patient often failed for another. Effective social needs work requires flexibility, local knowledge, and continuity which are elements not easily scaled through digital tools or vendor platforms.

Partnerships Can Bridge Resource and Insight Gaps

The UK collaboration also underscores the strategic advantage of linking academic programs to clinical operations. While many systems maintain research affiliations, few actively integrate public health students into care delivery. This approach builds future workforce capacity, enhances institutional alignment, and injects fresh analytic capability into under-resourced areas like community benefit evaluation and outcomes measurement.

More importantly, it reflects a governance model that treats SDOH not as peripheral to healthcare, but as integral to it. Students didn’t just observe. They participated. They weren’t assigned side projects. They contributed to patient care delivery and system design.

This level of engagement will become increasingly necessary as CMS, commercial payers, and state Medicaid agencies tie reimbursement to equity metrics, community engagement, and non-clinical risk mitigation. Hospitals that can’t demonstrate action beyond screening may soon find themselves at a disadvantage in both compliance scoring and market positioning.

Data Without Context Is a Missed Opportunity

As systems collect increasing volumes of social needs data, analytic maturity will become a critical differentiator. UK HealthCare’s partnership included structured data evaluation to examine how social needs correlate with clinical outcomes, a foundational step for any organization seeking to translate SDOH investment into value-based care readiness.

Yet many health systems lack dedicated analytic frameworks for SDOH data. According to Health Affairs, only a minority of hospitals currently integrate social risk information into clinical decision-making or population health strategy. Without standardized taxonomies, shared definitions, and interoperable documentation workflows, SDOH data risks becoming static, collected but unused.

Effective programs must address not only the technical architecture of data capture but the operational incentives that ensure follow-through. This includes aligning clinical quality goals with social care integration, embedding SDOH metrics into executive dashboards, and supporting community-based organizations whose capacity is often overwhelmed by referral surges with no added funding.

A Structural Commitment, Not a Programmatic Fix

Ultimately, what UK HealthCare has built is not just a screening and referral program. It is a structural commitment to integrating public health principles into care delivery. By recognizing that transportation, food access, and housing stability are clinical issues, not ancillary ones, the institution is modeling a future state that many others will be pushed to adopt, either by regulation or necessity.

For systems facing implementation fatigue or unclear ROI on SDOH investments, this partnership offers a replicable path forward. It leverages existing academic capacity, embeds future public health leaders into real care environments, and uses data to iteratively refine both intervention and strategy.

The broader lesson is clear: compliance with social needs mandates must evolve into a durable capability, not a checkbox. Screening is the start. Coordination, data analysis, and human-centered problem solving are what deliver impact.