Health & Social Needs

To reduce health disparities, we will advance a collaborative system, across sectors, that enables and facilitates the integration of social needs and health care.



A 2018 Physicians Foundation survey of nearly 9,000 United States physicians found 88 percent of doctors surveyed indicated that some, many or all of their patients had at least one social need that “pose(d) a serious impediment to their health.”



Already, there is an overwhelming amount of evidence demonstrating that having access to stable and affordable housing, healthy food, a good education, and steady income impact anyone’s ability to live a healthy life, even more so than access to clinical care itself.



In addition, when such basic social needs go unmet they become the principle drivers of health disparities—something we’ve witnessed both regionally and nationwide in the coronavirus pandemic, which has had disproportionately deadly outcomes in minority communities.


Unmet social needs are directly associated with a number of entrenched health issues, including:

  • Nearly twice the rate of depression;
  • 60 percent higher prevalence of diabetes;
  • More than 50 percent higher prevalence of high cholesterol and elevated hemoglobin A1c, which is a signal of diabetes;
  • More than double the rate of emergency department visits; and
  • More than double the rate of no-shows to clinic appointments.

In addition, poverty, disability, housing instability, and residence in a historically Black or low-wealth neighborhood have been found to be associated with higher hospital readmission rates.

Recently, many stakeholders—state Medicaid agencies, policy makers, payers, providers and health plans as well as community-based services—have begun to recognize the importance of broadening medically-focused care programs to include elements that address social needs.

  • We seek to make a strong business case for investing in addressing patients’ social needs as a core strategy for healthcare organizations.
  • We will help advance an enabling environment that can pave the way for the implementation of promising social interventions that can lead to improved health outcomes and greater coordination and integration of social and medical care.

We are interested in projects that:

  • Facilitate connections and collaboration between stakeholders across the health care and social services sectors to address the social needs of low-income South Florida residents.
  • Support the adoption of technology platforms, within a collaborative infrastructure, that allow for increased efficiencies in the referral of patients and clients in need of health and social services
  • Support implementation, evaluation and scaling of social needs interventions, such as medical-legal partnerships and food pharmacies.
  • Advocate for and inform health care financing and payment mechanisms for social needs interventions.

For more information on these and other efforts that advance a system of health that integrates health-related social needs as a standard part of clinical care in South Florida, please contact Director of Policy and Public Affairs Natalie Castellanos.

Our Impact Stories

Legal Aid Service of Broward County serves Memorial Primary Care patients to address ailments outside traditional medicine’s reach.

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