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Social Care Services Evidence Table: Screening and 

Assessment Functions

This evidence summary includes a broad range of research/resources on screening and assessment functions and is primarily focused on health 

care impact. It is not intended to be an exhaustive compilation of research/resources on this topic. The information presented in this summary 

can inform the value proposition of partnering with a community-based organization (CBO) or a network of CBOs to offer these services and 

supports as part of a strategy to address social determinants of health (SDOH).

As part of the core functions outlined in the No Wrong Door (NWD) System model, aging and disability networks routinely conduct screening and 

assessments to identify service needs and connect individuals to relevant services and programs. In states that participated in the Balancing 

Incentives Program (BIP), aging and disability organizations that comprise the state’s NWD system have implemented initial screenings (Level I

Assessment) that collect financial and functional data and point to potential needs and program eligibility, as well as assessments that provide a 

more complete picture of an individual’s abilities and needs (Level II Assessment). 

Increasingly, health care providers and systems are interested in identifying the unmet needs of the individuals they support that may in turn 

affect their health status and utilization. SDOH screenings and functional assessments are two ways in which health care systems to gather this 

type of member-level data. These tools can be defined as follows: 

• Screening for the SDOH: Screening tools and processes aimed at addressing health equity and barriers to care. SDOH screening tools 

come in many variations, however, most cover the domains of finances, education, food, housing, and transportation.1

• Functional Assessment: The process that captures and analyzes a person’s general behavior and capabilities to interact with the world, in 

order to determine his or her changing needs.2

The Centers for Medicare and Medicaid Services, the National Academies of Sciences, Engineering, and Medicine, the American College of 

Physicians, and the American Academy of Pediatrics have all expressed support for screening for SDOH in health care settings to begin address 

SDOH which are increasingly recognized as playing a powerful role in individuals overall health.

3

Likewise, research suggests that functional 

status information is among one of the most predictive elements of health care utilization and health outcomes.4In addition to ensuring that an 

1 https://www.bmc.org/healthcity/sdoh-screening

2 https://www.leadingage.org/white-papers/functional-assessment-and-activity-monitoring-technology-primer-and-provider-selection

3 https://www.healthaffairs.org/do/10.1377/hblog20190520.243444/full/

4 https://www.ncvhs.hhs.gov/wp-content/uploads/2017/08/010617rp.pdf 
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individual’s health care is appropriately tailored to best meet their specific needs and is tracked consistently over time, functional status 

information can directly benefit health providers, payers, and policymakers. Functional status information could provide valuable insight for 

financial management, utilization, and quality assurance. This data can be used to evaluate treatment outcomes, compare treatment modalities, 

measure health care performance, and predict expenditures. Additionally, this information can be used to calculate risk adjustments, document 

medical necessity, and adjust payment levels.5

Health care systems and clinical sites often experience challenges to implementing screening and functional assessment such as: time and 

resources constraints that impede data collection and the ability to gather accurate information; limited knowledge of local resources and 

services to support referrals; and limitations in regard to what services and supports can be reimbursed or paid for by the health care system. 

CBOs that comprise the disability and aging network are uniquely qualified to partner with health care organizations to screen and assess

individuals in their community. Aging and disability networks are recognized as trusted members of their communities with strong ties and 

knowledge of local resources. Staff of CBOs often reflect the communities which they serve in regard to both language and culture, promoting 

culturally and linguistically responsive services and supports. In addition to culturally responsive services and supports, the aging and disability 

networks have the potential to embed the following area of expertise into their screening and assessment approaches:

• Evidence-based practices and models in engaging individuals (ex. person-centered practices, trauma-informed care)

• Expertise in engagement (ex. motivational interviewing and coaching, promotion of self-advocacy skills)

• Navigation resources and expertise6

Aging and disability networks are well positioned to bridge the screening and assessment processes with referral linkages due to their expertise 

in navigation (See Navigation Access Function table) and local community resources. Partnering with CBOs that comprise the aging and disability 

networks to support functions such as screening and assessment has the potential to save costs, reduce duplication of efforts, close the loop on 

referrals, and provide culturally responsive supports for individuals. 

Research and resources related to screening and assessment functions provided by aging and disability networks are included below. 

5 https://www.ncvhs.hhs.gov/wp-content/uploads/2017/08/010617rp.pdf 

6 https://www.practicalplaybook.org/blogs/why-public-healthhealthcare-should-partner-community-based-organization-address-social-determinants
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Screening & Assessment Functions Research

Study Population Studied Objective of Study Type of 

Analysis

Findings / Results

Wallace et al. (2020) 210 emergency department 

patients in Utah; data were 

linked from the patients’ 

social needs screening to 

electronic health records 

and interview notes.

To evaluate a process for 

systematically identifying 

social needs during routine 

health service delivery to 

facilitate access to 

community-based services 

and integrate existing 

clinical and communitybased referral data systems. 

Two phase, 

mixed -

methods 

feasibility 

study

Three months post-screening 

showed that patients with social 

needs experienced a significant 

increase in emergency 

department use compared to 

those without social needs.

Samuels-Kalow et al. (2020) 16 emergency department 

(ED) patients and six staff 

members from regional 

community organizations

To identify the range of 

opinions regarding EDs 

based social risk screening 

held by patients and staff. In 

depth, qualitative interviews 

were conducted with a 

selected sample of ED 

patients and staff. Health 

literacy assessments were 

also conducted. 

Qualitative 

interview 

analysis

The interviews revealed that 

participants held three main 

opinions toward ED: social risk 

screening is important; 

challenges around screening 

include fear, mistrust, and 

resource constraints; and there 

is room for program 

improvement and development.
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Screening & Assessment Functions Resources

Resource Author Description of Content Target Audience

The Commonwealth Fund The Return on Investment (ROI) 

Calculator for Partnerships to 

Address the Social Determinants of 

Health is designed to help CBOs and 

their health system partners plan 

sustainable financial arrangements 

to fund the delivery of social 

services to high-need, high-cost 

patients. 

Health systems, payers, medical providers, social service providers, 

and CBOs seeking to address SDOH.

Center for Consumer 

Engagement in Health Innovation

(2018)

This brief aims to provide an 

overview of social needs screening 

tools, as well as options and 

considerations for implementing 

social needs referral tools and 

processes.

Consumer health advocates looking for effective and culturally 

competent use of social need referral tools in state public programs. 

Borras-Fernandez et al. (2016) This article provides an overview of 

functional assessments and their 

relevance to clinical practice. It 

contains a detailed table of a 

number of different functional 

assessments used across various 

fields.

Physicians or health care practices interested in adopting functional 

assessments and curious about the functional assessments that 

currently exist and are used.

Subcommittee on PopulationsNational Committee on Vital and 

Health Statistics (2017)

This article defines functional status 

and assessments, provides an 

overview of how functional 

assessments are used in clinical 

settings, and details some common 

challenges.

Physicians or health care systems interested in learning the utility of 

functional assessments in clinical settings.
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Resource Author Description of Content Target Audience

The EveryOne Project (2019) This guide includes an introduction 

to social needs screening, an 

overview of guidelines for various 

roles and responsibilities related to 

social needs screening, a 

description of a number of SDOH 

and their importance, and links to a 

number of resources.

Organizations or health systems looking to adopt social needs 

screening and are interested in learning more about the practice 

and discovering relevant resources. 

Olson et al. (2019) This article provides an overview of 

SDOH screening, describes the 

challenges historically faced by 

health care institutions, and details 

opportunities for improvement.

Health systems looking to adopt SDOH screening or currently facing 

challenges and are interested in exploring potential solutions.