Find Every Unmet Social Need. Close Every Referral. Prove What Worked.
SDOH Solutions gives health plans, FQHCs, clinics and care teams one place to record health-related social needs, coordinate referrals to community resources, and measure outcomes, with FIPS-code mapping that shows where needs concentrate.
HRSN vs. SDOH: Which Term Applies to You?
HRSN software, defined
HRSN software records an individual’s unmet social needs (food, housing, transportation, utilities), connects them to community resources, tracks each referral until it is resolved, and reports whether the intervention worked. SDOH software adds the community view: where those needs cluster across a service area.
| Term | Level | Meaning | Typical use |
|---|---|---|---|
| HRSN Health-related social needs | Individual | A specific person’s unmet need, such as no reliable food, housing, or transportation. | Screening, referrals, care coordination, Medicaid and HEDIS programs. |
| SDOH Social determinants of health | Community | Conditions where people live and work, such as poverty rate, neighborhood safety, food access. | Population health strategy, community mapping, resource planning. |
| Social drivers of health | Community and individual | The term CMS uses on its own pages, alongside SDOH and HRSN. | Federal guidance and quality programs. |
| Upstream drivers | Billing language | Wording CMS adopted in the CY 2026 fee schedule in place of “social determinants” for community health integration services. | Medicare billing descriptors. |
The Language and Codes Are Shifting. The Needs Are Not.
Federal requirements around social needs are being rewritten. Here is what changed, so you can plan around facts rather than headlines.
CMS withdrew its HRSN framework
On March 4, 2025 CMS rescinded its guidance on covering health-related social needs through Medicaid and CHIP. Existing state approvals were not cancelled, but renewals are now uncertain.
CMS informational bulletin →SDOH screening left the MSSP quality set
For 2026 CMS removed the Screening for Social Drivers of Health measure (Quality ID 487) for ACOs and reworded several billing descriptors away from SDOH language.
ICD10 Monitor analysis →HEDIS keeps a social need measure
NCQA's Social Need Screening and Intervention measure continues, with some MY 2026 code additions retracted after the fee schedule change.
NCQA update →Many plans still fund social needs
Medicaid managed care plans can offer in-lieu-of services for social needs, and the 2024 managed care rule broadened that option with new oversight.
Georgetown CCF explainer →What it means for your team: there is no single national mandate to point to, so programs are driven by state contracts, accreditation, and your own outcomes goals. A platform you can configure, and that documents needs and results consistently, protects you whichever way the rules move.
Most Teams Manage Social Needs With Tools Built for Something Else
Social barriers stay invisible until they become claims
Without a shared view of member needs, high-risk members surface in the ER or in your quality scores first.
- Screening results scattered across surveys and systems
- No map of which communities need which resources
- Hard to show that outreach changed utilization
Coordinators track referrals in spreadsheets
Screening may be happening, but referrals live in notebooks and memory, so closing the loop takes hours.
- Referral status unknown after handoff
- Hours lost to manual status checks
- No view of which partner resources actually help
Social risk data exists but is not connected
Surveys, claims, and screener data sit in silos, so leadership cannot see where to direct resources.
- Needs data fragmented across tools
- No geographic view of need by community
- Little visibility into return on community investment
From Screening Data to Closed-Loop Outcomes in One Platform
See the whole picture
Map your population by social need and location, down to the FIPS code.
- Member needs placed on local maps
- High-need communities identified
- Population trends across the service area
Connect and coordinate
Match people to local resources and manage every outreach and referral.
- CRM-lite member management
- Resource matching to local partners
- Referral and outreach history in one record
Measure and improve
Track progress and learn which interventions are working.
- Outcomes analytics and reporting
- Real-time updates for the whole team
- Leadership visibility into impact
Built for Social Needs Work, Not Retrofitted From a Sales CRM
Every capability below ties to a part of the HRSN workflow: identify, coordinate, and measure.
FIPS-code community mapping
See where needs concentrate by geography so you can place resources where they matter most.
Social needs tracking
Record each member's identified needs and keep that history current as circumstances change.
CRM-lite member management
Outreach history, notes, and progress for every member, designed for care coordinators.
Referral tracking
Match members to local partners and follow each referral until the need is resolved.
Outcomes analytics
Report on intervention effectiveness for leadership, funders, and quality programs.
Fully configurable
Set your own local partners, social needs categories, and workflows.
HRSN Software for Every Type of Care Organization
Give member outreach a map and a record
See social needs across your membership and coordinate outreach with local resources.
- Locate high-need communities by FIPS code
- Track outreach and referral outcomes
- Report impact to leadership and partners
Replace spreadsheet tracking for social needs
Keep screening follow-up, referrals, and outcomes in one system your whole team can see.
- Manage referrals from open to resolved
- Cut manual tracking time for coordinators
- Show partners and funders what changed
Address the barriers undermining clinical care
Surface the social barriers behind missed appointments and repeat visits.
- Equip coordinators with a dedicated platform
- Track partner resource follow-through
- Give leadership a clear view of impact
A right-sized platform for smaller teams
Start with the capabilities your team needs and configure the rest as you grow.
- Clinics Edition for smaller organizations
- Population analytics across the service area
- Configurable workflows and partners
Turn Social Needs Work Into Reportable Results
HRSN Questions, Answered
What are health-related social needs (HRSN)?
Health-related social needs (HRSN) are an individual's unmet social circumstances that affect their health, such as food insecurity, unstable housing, lack of transportation, utility shutoffs, financial strain, and social isolation. HRSN describes one person's need that a care team can act on, rather than a community-wide condition.
What is the difference between SDOH and HRSN?
SDOH (social determinants of health) are community-level conditions, such as poverty rates, neighborhood safety, and access to healthy food. HRSN (health-related social needs) are the individual-level needs those conditions create for a specific patient or member. CMS also uses the phrase social drivers of health. SDOH is the context; HRSN is the actionable signal for care coordination.
What is HRSN software?
HRSN software helps healthcare organizations record individual social needs, match people to community resources, track each referral until it is resolved, and report outcomes. SDOH Solutions adds FIPS-code community mapping so teams can also see where needs cluster across their service area.
What is HRSN screening?
HRSN screening is a short set of standardized questions that asks patients or members about needs such as food, housing, transportation, and utilities. Widely used instruments include the CMS Accountable Health Communities HRSN tool and PRAPARE. Screening results only help when they lead to a documented referral and a follow-up on whether the need was met.
Is HRSN screening still required in 2026?
There is no single federal requirement, and the landscape is shifting. CMS rescinded its Medicaid HRSN framework in March 2025 and removed the SDOH screening measure from MSSP quality reporting, while NCQA's HEDIS Social Need Screening and Intervention measure continues. Requirements now depend on your state, contracts, and accreditation, so confirm what applies to your organization.
What is closed-loop referral tracking?
Closed-loop referral tracking follows a referral from the moment a need is identified until you confirm the person received help. Many teams can send a referral but cannot say whether it worked. A closed loop records the status, prompts follow-up on stalled referrals, and captures the outcome.
How can SDOH Solutions help reduce avoidable ER visits?
SDOH Solutions helps care teams see social barriers earlier, coordinate outreach and referrals in one place, and measure whether interventions change outcomes. Earlier intervention on needs like transportation, food, and housing can reduce avoidable emergency use, and outcomes analytics let you check whether it is happening in your population.
What happens in a demo?
A demo is a live walkthrough of community mapping, member management, referral tracking, and outcomes analytics, followed by a conversation about how the platform can be configured for your partners, social needs categories, and workflows.
See Your Population’s Social Needs on One Map
A live walkthrough tailored to your organization type.
- Community mapping and member management
- Referral tracking and outcomes analytics
- Configuration for your partners and workflows
Sources
- CMS Accountable Health Communities preliminary findings fact sheet
- CMS: Social Drivers of Health and Health-Related Social Needs
- CMS informational bulletin rescinding HRSN guidance (March 4, 2025)
- ICD10 Monitor: The Removal of SDoH from the 2026 Final Rule
- NCQA: Social Need Screening and Intervention changes for MY 2026
- Georgetown CCF: Medicaid managed care in lieu of services explained
- Acuity: Medicaid 1115 HRSN waivers, rescinded guidance and renewal risks
Last reviewed October 2026. Policy information is summarized for general awareness and is not legal or compliance advice; confirm requirements with your state agency, contracts, and counsel.