June 2020 | Technical Assistance Tool


Attention to health-related social needs is particularly critical to addressing COVID-19 and reducing health disparities. Given the significant influence of social needs on the health of Medicaid beneficiaries and their overall cost of care, there is increasing interest in maximizing the impact of social needs interventions and avoiding duplication of services. Government agencies, health plans, and providers can benefit from defining the unique roles that each can play in coordinating services to meet social needs. These cross-sector partners may be able to do more with less by mapping out complementary activities that support shared goals for improving the health and wellbeing of this population.

This framework was developed to support Medicaid agencies, managed care organizations, health care providers, and community partners in mapping cross-sector partnership roles for addressing health-related social needs based on the strengths of each stakeholder. Activities included in the framework are organized under five key categories for addressing social integration — awareness, adjustment, assistance, alignment, and advocacy — as outlined in the National Academies of Sciences, Engineering, and Medicine report, Integrating Social Care into the Delivery of Health Care.