Know what your population really needs, and act on it.
Censa by SDOH Solutions lets you build custom SDOH assessment surveys to get the details you need on your population, then turns every answer into action: flagged needs, local referrals, and outcomes you can report on, all in one place.
For health plans, FQHCs, clinics, and population health teams. Cloud-based, nothing to install.
Do you have reliable transportation to appointments?
How often is it hard to afford groceries?
2 local resources matched. Referral ready to send.
Quick answer
What is Censa?
Censa is cloud-based social determinants of health (SDOH) software from SDOH Solutions in Houston, Texas. It helps health plans, FQHCs, clinics, and population health teams see which communities need which resources, connect people to local help, track each referral until it closes, and report the outcomes.
- ProductCensa by SDOH Solutions
- CategorySDOH and HRSN software
- Built forPayers, FQHCs, clinics, population health and VBC teams
- DeploymentCloud-based, browser access
- Core jobsMap needs, manage members, match resources, track referrals, measure outcomes
- Based inHouston, Texas
The problems Censa solves
Why do social needs programs stall?
Most teams already know housing, food, and transportation drive utilization. The hard part is seeing it, acting on it, and proving it worked.
Social barriers stay invisible until they show up in the ER
A missed ride, an empty fridge, or an unstable living situation rarely appears in claims until it becomes an avoidable visit or readmission.
Goal: fewer avoidable ER visits and readmissions
SDOH data is scattered across spreadsheets and surveys
Screening results live in one tool, referrals in another, and partner updates in email. No one has the full picture.
Goal: one source of truth for social needs work
Care coordinators spend hours on manual tracking
Calling partners, updating spreadsheets, and rebuilding the same lists every week pulls staff away from members.
Goal: fewer coordinator hours spent on admin
Quality and value-based care metrics slip
When you cannot show that a need was screened, addressed, and followed up, measures and shared-savings performance suffer.
Goal: stronger quality and VBC performance
No clear view of which communities need which resources
Without location-level data, outreach dollars and partnerships get spread thin or placed in the wrong neighborhoods.
Goal: resources placed where they matter most
Organizations that use Censa
Who is Censa built for?
Censa supports any organization responsible for connecting people to social resources and showing the results. These are the teams that get the most from it.
Health plans and payers
VP Population Health, Director of Care Management, Quality and VBC leads
- Find members with unmet social needs across your service area
- Track screenings and interventions through to a documented result
- Coordinate closed-loop referrals with community partners
Medicaid managed care organizations
Medicaid program leaders, care management, community partnerships
- See social needs by county across your Medicaid footprint
- Organize resource referrals and partner data in one place
- Support state-specific non-medical drivers of health (NMDOH) programs
Federally qualified health centers (FQHCs)
Executive Directors, CHW and enabling-services managers, grants and reporting staff
- Give community health workers one place to log needs and referrals
- Show your board and funders where needs concentrate in your area
- Pull community-level data for grant applications and reports
Clinics and provider organizations
Practice administrators, care coordinators, clinical operations leaders
- Document social needs and follow-up without extra spreadsheets
- Follow up on patients at risk of readmission due to social barriers
- Keep referral history ready for value-based contracts
Population health and value-based care teams
ACO leaders, Chief Health Equity Officers, analytics and quality teams
- Prioritize communities and members with the greatest social risk
- Measure which interventions actually close needs
- Report outcomes to leadership and contract partners
Community-based organizations and partners
Food banks, housing agencies, transportation and social service providers
- Receive referrals from healthcare partners in a structured way
- Update status so the referring team knows the need was met
- Show the community impact of your services
The Censa platform
What does Censa do?
Four connected tools that take you from “where is the need?” to “here is the result.”
Community mapping
See social needs at the FIPS-code (county) level to target outreach, partnerships, and resources.
Member management
A lightweight CRM for social needs: screenings, notes, and history for every member or patient.
Resource matching and referrals
Match people to local resources and track each referral from sent to closed.
Outcomes analytics
Report on needs identified, referrals closed, and results by community, program, or team.
How it works
How does Censa close the loop on social needs?
Identify
Build custom SDOH assessments, capture social needs, and see where they concentrate on the community map.
Match
Connect each member or patient to the right local resource for their need.
Track
Follow every referral from sent to in progress to closed, with partner updates in one place.
Prove
Report outcomes to leadership, funders, and contract partners with data you trust.
Built for today’s reporting
What SDOH reporting can Censa help with?
Federal SDOH requirements shifted in 2025, but plenty of programs still ask you to show that social needs were identified and addressed. Censa helps you organize that work.
HEDIS social need screening
Keep screening and intervention records together for the Social Need Screening and Intervention (SNS-E) measure.
Community health integration
Keep a clear record of who addressed which upstream driver and what happened next.
FQHC and grant reporting
Show needs and services by community for UDS context, board updates, and funders.
State NMDOH programs
Organize non-medical drivers of health work for state Medicaid programs, including Texas.
FAQ
Frequently asked questions about Censa
What is Censa?
Censa is cloud-based social determinants of health (SDOH) software from SDOH Solutions in Houston, Texas. It helps health plans, FQHCs, clinics, and population health teams see social needs by community, connect members and patients to local resources, track each referral until it closes, and report on outcomes.
What is SDOH software?
SDOH software helps healthcare organizations capture social needs such as food, housing, and transportation, connect people to community resources that address those needs, and measure the results. It replaces spreadsheets and disconnected surveys with one shared record.
Who uses Censa?
Censa is used by health plans and payers, Medicaid managed care organizations, federally qualified health centers (FQHCs), clinics and provider organizations, hospital and health system population health teams, value-based care and ACO teams, and the community-based organizations that partner with them.
What is closed-loop referral tracking?
Closed-loop referral tracking means following a referral from the moment it is sent to a community resource until there is a documented result, such as the person receiving the service. It shows care teams which needs were actually resolved instead of only which referrals were made.
How does community mapping by FIPS code help?
FIPS codes identify US states and counties. Mapping social needs at that level shows which communities carry the most food, housing, or transportation barriers, so teams can place outreach, resources, and partnerships where they will matter most.
Does Censa replace our EHR or care management system?
No. Censa focuses on social needs work: community data, resource matching, referral tracking, and outcomes reporting. It is designed to sit alongside existing clinical and care management systems. Integration options are reviewed during the demo.
How do we get started with Censa?
Request a free demo. The SDOH Solutions team will walk through your population, your current SDOH workflow, and the reporting you need, then show how Censa fits and what implementation looks like.
See your communities’ social needs in one view
Get a live walkthrough of Censa built around your population, your workflow, and the outcomes you report on.
- Community map tailored to your service area
- Referral tracking walkthrough
- Reporting matched to your programs