Food, transport, shelter, and a helpful voice to guide you
For five years, Penn Medicine’s Social Needs Response Team has connected patients to vital support foundational to good health.
“If you don’t know when your next meal is going to be, then taking your medication on time or even going to your doctor’s appointment is not a priority,” said Ana Bonilla Martinez, BS, CHES, program manager of Penn Medicine’s Center for Health Equity Advancement (CHEA).
Bonilla Martinez, who coordinates Penn Medicine’s Social Needs Response Team, sees firsthand how food insecurity, housing instability, unemployment, lack of transportation, and other factors can significantly impact a person’s ability to prioritize or maintain their health.
Since 2020, the team has been helping patients by directly addressing health-related social needs like these—an effort that has not only helped people in Philadelphia and surrounding regions manage underlying needs that impact their health, but has enhanced the way Penn educates future health care providers.
Two needs, one novel solution
The Social Needs Response Team was originally established by CHEA and the Hospital of the University of Pennsylvania Department of Social Work and Case Management to deal with health-related social needs in the Philadelphia community that were worsened by the COVID-19 pandemic, such as unemployment and food insecurity, as well as mental health concerns. The program also filled a critical educational gap for medical students at a time when their required clinical rotations were paused during the early months of the pandemic.
To serve both needs, program leaders created virtual teams comprising two to four medical students per shift, along with a licensed clinical social worker to provide instruction and oversight. At first, patients were referred primarily by Penn Medicine clinicians in community settings, such as COVID-19 testing sites, then later vaccine clinics.
Help starts with a phone call. Medical students are taught to use scripted questions and techniques that foster understanding when reaching out to referred patients to assess their needs. They begin by asking about safety and distress before turning to social questions like: Do you have enough food to eat? Do you have access to transportation to get to your health care appointments? Are you experiencing social isolation?
It's one thing to hand a patient a sheet of paper listing numbers to call, but to proactively call an at-risk patient, engage them in conversation to understand their needs, and then work with them to get help is another thing entirely. It’s a lifeline.
After documenting the encounter and triaging (prioritizing by urgency) each need, they connect those patients to appropriate resources for support—for example, helping the patient enroll in a food assistance program or find transportation for their medical appointments, or escalating safety concerns to a social worker for intervention.
Jaya Aysola, MD, DTMH, MPH, an associate professor of General Internal Medicine and the founder and executive director of CHEA, explained that as COVID-19-related resources were phased out and patients were still facing similar barriers, it became evident that the team’s work was filling a vital role in the community.
“There was a need, beyond the pandemic, for a virtual care team to step in and serve as an extension of our social work program,” Aysola said.
Measuring the problem—and stepping up to help
Five years later, with more than 12,000 patient encounters, the Social Needs Response Team is still going strong. There are now multiple entry points for referrals at Penn, including outpatient providers and care managers, and inpatient nurses and social workers at all Penn Medicine hospitals—with more than 60 percent located in Philadelphia.
What distinguishes the program and propels its impact is that it deploys technology and data across the spectrum—and combines that with hands-on, personal outreach. Before a medical student picks up the phone to call a patient, Penn Medicine has already gained insight that the patient is likely to have some unmet social needs based on screening questions they answer while they’re in the hospital or visiting an outpatient facility for care. Then, the Penn Medicine team follows protocols to ensure that these needs don’t slip through unnoticed and there’s a handoff for appropriate follow-up. After the call, Penn Medicine uses a variety of home-grown technologies, trusted partnerships, and other proven tools to respond to those needs with compassionate support.
It's one thing to hand a patient a sheet of paper listing numbers to call, but to proactively call an at-risk patient, engage them in conversation to understand their needs, and then work with them to get help is another thing entirely. It’s a lifeline.
Screening for health-related social needs
“Health care does not exist in a vacuum. Understanding the various challenges and barriers patients face that could impact their physical and mental well-being and providing resources to address those barriers is critical to improving outcomes and ensuring patient-centered, equitable, high-quality care,” said Rose Thomas, MPH, director of operations for CHEA.
How do you reach that understanding? Ask.
Since 2019, Penn Medicine has included a set of evidence-based questions in its electronic health record to screen patients for health-related social needs. In September 2023, Penn integrated health-related social needs screening questions to inpatient workflows at all of its hospitals—meaning that at least once during their stay, most patients were asked by a provider about their access to food, shelter, transportation, and other non-medical needs that could impact their health.
In January 2024, the rest of the country caught up as the Centers for Medicare & Medicaid Services (CMS) began mandating universal screening for health-related social needs for all adults admitted to the hospital.
PA Navigate
While screening for needs is a positive step toward whole-patient care, actually helping patients meet their needs is the larger goal.
Back in 2019, before there was a Social Needs Response Team, Aysola and her colleagues recognized the importance of connecting patients who screened positive for health-related social needs with community-based organizations that can help. They embedded a platform called PA Navigate into Penn Medicine’s electronic health record, offering providers a directory of local resources categorized by social need and zip code.
Today, PA Navigate is among the tools regularly relied upon by the Social Needs Response Team. Patients, community members, and staff can directly search online to find support for concerns such as housing and utilities, safety and recovery counseling, childcare, legal and financial, and much more.
The Social Needs Response Team offers patients an additional layer of support by helping them use this tool, including assisting with applications and initiating three-way calls, linking community resources with those who need to access their services. An evaluation of patients contacted by the Social Needs Response Team from Nov. 13, 2023 to Nov. 1, 2024 identified navigation assistance as a top need. The leading five needs were as follows, with one in three patients reporting multiple needs:
34% Social needs screening and navigation assistance
30% Food insecurity
16% Transportation
16% Housing/shelter
9% Behavioral health resources
Additional needs included medication, benefits, health care services, utilities, caregiver support, and legal resources.
Since the Social Needs Response Team’s inception, Aysola and her team have studied data about the patients they’ve connected with to better understand the most common needs in our community. Their findings have been published in journals such as NEJM Catalyst, Frontiers in Public Health, and BCPHR (formerly Harvard Public Health Review).
The leadership team of Deborah Lowenstein, LCSW; Heather Klusaritz, PhD, MSW; Preeti Advani, MSW, LSW; Patricia Meehan, LSW; Rose Thomas, MPH; Ana Bonilla Martinez, BS, CHES; and Jaya Aysola, MD, DTMH, MPH, continue to meet regularly to refine this novel model of care in response to growing and evolving needs.
Food Access Support Technology (FAST)
It’s not surprising that almost a third of patients helped by the Social Needs Response Team have experienced food insecurity, defined as not having enough to eat and not knowing where your next meal will come from. Food insecurity is a leading social need in the Greater Philadelphia region. According to Feeding America’s most recent Map the Meal Gap report (2022 data), 472,250 food-insecure individuals live in Philadelphia, Montgomery, Delaware, Chester, and Bucks Counties. Among those, 51.4 percent reside in Philadelphia County.
One way the team is able to help patients who are experiencing food insecurity is the FAST program, a digital platform also created by CHEA. FAST connects health care systems, community-based organizations, and minority-owned small businesses to respond in real time to food insecurity.
When a patient is identified as food insecure, the referring provider, social worker, or Social Needs Response Team member posts on the FAST site, and organizations that can offer food and delivery services reply directly to fulfill the request. Groups that previously operated in siloes can now quickly and easily coordinate to provide medically appropriate meals to the most vulnerable community members. To date, the FAST program has served more than 10,000 people.
Fostering empathy in future health care providers
The Social Needs Response Team has expanded beyond Penn’s medical school to serve as a clinical elective for other Penn health sciences students, including nursing, public health, social work, dentistry, and veterinary medicine. Students interact with subspecialists, clinicians, and ancillary care providers in ways they otherwise wouldn’t until later in their careers.
More importantly, working with the Social Needs Response Team trains students to take an approach of empathetic inquiry: asking questions rather than dictating what the patient should do, and learning from the patient what they hope to accomplish on the call. They come away with core skills in human-to-human connection that will benefit them—and their future patients—as medical professionals.
“Social needs can be so debilitating, and when it comes to seeking help, people don’t know where to start,” Aysola said. “Offering services in a way that’s not patronizing or stigmatizing, but actually empowers patients, is probably the most impactful aspect of the program.”