✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 22, 2025.
Health-related social needs (HRSN) identify the adverse social conditions that directly impact a specific individual’s health outcomes. Among the most widely used HRSN screening tools are the Accountable Health Communities (AHC) tool, PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences), and the Health Begins tool. By identifying a client’s HRSN and connecting him to appropriate resources, the case manager can reduce health disparities and improve outcomes.
Common health-related social needs and associated resources
Access to healthcare
Many people face barriers that prevent or limit access to healthcare, such as lack of health insurance, poor access to transportation, and limited healthcare resources in their geographic area.
Resources to address healthcare access
- Federally qualified health centers (FQHCs), which provide care regardless of a patient’s ability to pay
- Sliding-fee-scale clinics
- Medicaid and Medicare
- Healthcare marketplace navigators to assist with insurance enrollment
- Healthcare transportation assistance programs
- Non-emergency medical transportation (NEMT) programs
- Rideshare programs
Access to foods that support healthy eating patterns
Studies show a relationship between adverse health outcomes and the inability to access foods that support healthy eating patterns. For example, a study of 40,000 California residents examined the impact of access to healthy foods on rates of obesity and diabetes. Residents of neighborhoods with few fresh produce sources and plentiful fast-food restaurants and convenience stores were at a higher risk of obesity and diabetes.
Resources to address access to healthy food
- Supplemental Nutrition Assistance Program (SNAP)
- Women, Infants, and Children (WIC) program
- Community food pantries
- Meals on Wheels
- Local food banks
- Community gardens
Housing instability
The term ‘housing instability’ encompasses multiple challenges, including trouble paying rent, overcrowding, frequent moving, staying with relatives, homelessness, or spending a large portion of the household income on housing. These experiences are associated with poor health outcomes, including hypertension and cardiovascular disease (Healthy People 2030, 2019), and make it harder to access healthcare.
Resources to address housing instability
- Housing assistance programs
- Housing Choice Voucher program (formerly known as Section 8 housing vouchers)
- Public housing
- Permanent supportive housing programs
- Emergency rental assistance
- Local housing coalitions
- Transitional housing programs
Utility services
The inability to maintain essential utilities (such as electricity, water, heating, and cooling) or concerns about utilities being shut off can contribute to chronic stress, respiratory issues, and other health concerns, particularly in extreme temperatures.
Resources to address utility needs
- Low-Income Home Energy Assistance Program (LIHEAP)
- Local utility company assistance programs
- Emergency assistance programs through social service agencies
- Weatherization Assistance Program (WAP)
Case manager impact on health-related social needs
Patients affected by social drivers of health often need CMs most, as they benefit considerably from case management services. They are the clients who will be in the ED repeatedly or labeled “non-compliant” because they cannot follow the treatment plan, resulting in suboptimal outcomes for the healthcare organization when their health-related social needs go unaddressed. Case managers can develop creative solutions by understanding how social drivers of health and HRSNs impact clients and the resources available.
This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, purchase your copy at CCMCertificationMadeEasy.com
