A member who can't afford groceries isn't going to follow a meal plan. One who keeps missing calls might not have a working phone, a ride or a steady place to sleep. Coaches usually find this out by accident, weeks in, after the plan has already stalled.
A few questions at the start catch most of it. The harder part is deciding what happens when someone says yes. Here's how we'd set up social needs screening in a coaching program, from the questions to the follow-up.
Why coaching programs ask about social needs
Coaching works on habits, and habits run on resources: food in the house, a way to get to the pharmacy, heat that stays on. When those are missing, the member isn't failing the program. The program is asking for something they can't do yet.
These needs aren't rare. CMS's Accountable Health Communities model screened more than a million Medicaid and Medicare members through doctors' offices, clinics and hospitals between 2017 and 2023, and 37% screened positive for at least one of five core needs. Your members may look different. If you serve health plan or Medicaid populations, expect plenty of yeses.
Which questions to use for social needs screening
You don't have to write these yourself. The most widely used free set is the 10 core questions in CMS's Accountable Health Communities tool. They cover housing, food, transportation, utilities and personal safety.
The two food questions are the best tested. They ask whether, in the past 12 months, the member worried food would run out before there was money to buy more, and whether food they bought didn't last.
A later test in U.S. adults recommended the same pair for clinical screening (Gundersen et al., Public Health Nutrition, 2017).
Check the terms before you load them into your platform. CMS's citation guide for the tool says any organization can use the food questions as long as it cites them. The authors of the housing, transportation, utilities and safety questions also ask to be told before an organization uses them, and the guide lists who to contact.
Who asks, and when
We'd put the questions on the health coaching intake form, then have the coach follow up on any yes in the first session. A form gives the member some privacy to answer honestly. The conversation is where help actually gets offered.
Most people don't mind being asked. In a survey of 969 patients and caregivers at primary care clinics and emergency departments in nine states, 79% said screening for social needs was appropriate (De Marchis et al., American Journal of Preventive Medicine, 2019). People who'd been treated unfairly in health care before were less comfortable with it. People who trusted their clinician were more comfortable.
So say why you're asking. Tell members the answers help the coach build a plan that fits their life, say who sees them, and make it clear a yes won't change their place in the program.
What to do when a member says yes
Ask whether they want help. A positive screen isn't a request. In a study of 1,021 adults at clinics and emergency departments, nearly 9% of people who screened negative wanted help anyway (De Marchis et al., JAMA Network Open, 2020).
The order of questions mattered, too. People with a need were more likely to say they wanted help when that question came before the screening questions. Asking "is there anything you'd like help with?" first is a small change that's easy to make.
Then have something to hand them. Build a short local list before launch: food pantries, rental help, rides to appointments, utility assistance. When a coach doesn't know what's available in a member's town, 211 does. It's a free, confidential line run by more than 200 local agencies, open 24 hours a day, and most of its calls are about housing, food, transportation and health care.
Follow up, because a list isn't help
The Accountable Health Communities model tested this directly. Members with a need were randomly split. Everyone got a list of local resources, and half were also offered a navigator who helped them reach those services. The group offered navigators ended up with lower health care spending and less hospital use than the list-only group, according to CMS's final evaluation report.
What's interesting is why. When CMS surveyed some of them six months after screening, both groups said their needs had been resolved at about the same rate. The evaluators' best guesses were that navigators built trust and helped with things like remembering appointments. They also heard from navigators that some communities simply didn't have enough resources to go around.
We'd add one check-in a week or two after any referral: did you reach them, and what happened? In the meantime, keep the coaching plan to what the member can do right now.
Where the coach's job stops
Coaches aren't social workers. They shouldn't promise housing, take over a benefits application or try to hold a crisis on their own. Their job is to notice, offer a referral, follow up and adjust the plan. Our guide to scope of practice covers where that line sits. If a member says they're in danger right now, that's a call to 911, not a coaching conversation.
Where Avidon fits
Avidon's drag-and-drop Flows tool builds intake forms and surveys with branching logic, so a yes on food can open a follow-up asking whether the member wants help, and everyone else skips it. Coaches can open a form and fill it in with a member during a call, and answers to questions saved in the question library show up in each member's record. It all sits on a platform that's HIPAA and GDPR compliant, ISO 27001 certified and SOC 2 attested. See how it works for chronic care and population health teams.
