In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

Although health centers have more options than ever to use electronic tools to engage patients in care, selecting those that most effectively further the goal of providing high-quality and efficient patient care is challenging. In this explainer, we consider three types of tools that health centers may invest in: Remote Patient Monitoring, Electronic Patient Engagement, and mHealth Personal Apps. By understanding what they are and how they are implemented, their advantages and disadvantages, and how they align with value-based care and the clinical workflow, health centers can choose the suite of tools that best serve their patient needs.

This Excel-based scoring rubric is intended to be used by health centers to assess electronic patient engagement tools (like automated outreach SMS platforms) to determine which tool is most likely to meet the health center's needs.