Connecting Patients to Community Resources

Question: Can hospitals report as community benefit programs that connect patients to resources in the community, like Health Leads? As more and more organizations focus on the social determinants of health, we are identifying workforce capacity to help patients connect to affordable housing, food security, and employment. Does this count as community benefit if it for our patients, but does go above and beyond clinical care?

Recommendation: Health Leads is a program used by healthcare providers to screen low-income families for basic needs such as food and heat that can affect their health and that connects them to community resources that meet those needs. We recommend that the costs associated with Health Leads be reported as community health improvement in the following circumstances:

Patients/individuals are referred for these services whether or not they are part of a population for which the organization bears financial risk (such as an ACO), and regardless of their insurance status. We also recommend that the hospital or healthcare organization sponsoring the Health Leads program identify needs associated with social determinants in their needs assessment/implementation strategy and indicate that Health Leads is part of a strategy to address those needs. The case is even stronger if the hospital or healthcare organization makes these services available to community members outside its patient population, such patients of an unaffiliated community clinic.

(December 2016)

Question: We are developing a program to screen low-income patients for social needs and to refer persons identified as having unmet needs to community services. Can these activities be reported as community benefit?

Recommendation: We recommend reporting the expense of screening for health-related social needs and follow-up referrals as community benefit under Category A3: Health Care Support Services when all of the following are met:

  • Community health need has been established (for example, housing and food security issues are present in community)
  • Activities are above and beyond the standard practice of discharge planning and not required by accrediting bodies for licensure or by third-party payers
  • Activity is provided for low-income and vulnerable persons
  • The organization operates the program in collaboration with other providers and agencies. 

If these criteria are met, the following expenses could be reported:

  • Staff time for development of policies, procedures and agreements with referral partners
  • Staff training
  • Staff time for screening and referral activities, beyond standard activities conducted for all patients
  • Technology used to facilitate screening, record findings, and for making and managing referrals.

(Be careful not to double count with community benefit operations or any other reported community benefit expenses.)

Do not report screening for health-related social needs and follow-up referrals when:

  • The activity is part of standard discharge planning or is required for licensure, accreditation, or by third-party payers
  • The activity is provided primarily to financially benefit the health care organization, such as to avoid re-hospitalization penalties, earn reimbursement incentives, or reduce Medicaid or financial assistance losses
  • The activity is limited to a subgroup of patients for which the organization bears financial risk, such as those that are part of the health care organization’s ACO/population health management program
  • The program excludes uninsured or Medicaid-covered persons


(May 2018)

Please Take Note: The information provided does not constitute legal or tax advice. The material is provided for informational/educational purposes only. Please consult with counsel regarding your organization's particular circumstances.