SDOH Screening and Referral in New York
SDOH screening is a short set of questions your primary care practice asks to identify social needs — food, housing, transportation, safety — that affect your health, followed by connection to community resources that can help. When a need is found, the practice documents it with a Z-code and links you to support, because those conditions often drive health outcomes more than the clinical visit itself.
A patient can do everything right in the exam room and still get worse at home. If there's no food, no stable housing, or no way to get to a follow-up, the treatment plan stalls. Screening for the social determinants of health — and acting on what it finds — is how primary care closes that gap.
The social determinants of health (SDOH) are the non-medical conditions that shape whether people stay well: income, food security, housing stability, transportation, education, social support, and safety. They influence a large share of health outcomes — more than the care delivered inside the clinic.
In behavioral health this matters even more. Depression and anxiety are harder to treat when someone is food-insecure, isolated, or unsure where they'll sleep. A medication or a therapy plan can't outrun an unmet basic need. Screening surfaces those needs so the care team can address them alongside the clinical problem.
SDOH screening is a brief, structured questionnaire completed during a primary care visit. Validated tools — such as PRAPARE or the Accountable Health Communities screener — ask about domains like:
The screen takes a few minutes and is usually completed at intake or during a routine visit. A positive answer isn't a diagnosis — it's a flag that a specific need exists and should be addressed. The point of screening is not the score; it's what happens next.
When screening identifies a social need, the practice records it using Z-codes — the ICD-10-CM codes in the Z55–Z65 range that capture social and economic circumstances affecting health. Examples include Z59.0 (homelessness), Z59.4 (lack of adequate food), and Z59.82 (transportation insecurity).
Z-codes turn a social need into structured, documented data. That has three practical effects:
Z-codes are widely under-used because screening is inconsistent and documentation adds work. A practice that screens routinely and codes what it finds builds a far more accurate picture of its patients than one that doesn't.
Documentation without action doesn't help anyone. The referral step is where screening becomes care. After a positive screen, the care team connects the patient to a community resource that fits the need — a food pantry or SNAP enrollment, a housing or benefits navigator, transportation support, or a domestic-violence resource.
Good referral is closed-loop: the team doesn't just hand over a phone number, it follows up to confirm the patient connected and the need was met. New York has a dense network of community-based organizations and, in many regions, health-information infrastructure meant to route these referrals — but only if someone in the practice is screening, documenting, and following through.
Integral Health embeds collaborative care in primary care practices across New York, and SDOH screening and connection to community resources is part of that care. The behavioral health care manager who supports the patient also screens for social needs, documents them with Z-codes, and connects the patient to community resources — inside the primary care practice the patient already uses.
That integration is the advantage. Because the same care manager is already checking in on symptoms with tools like the PHQ-9 and GAD-7, social needs surface in the same conversation as the behavioral health need — and get addressed together, rather than in a separate workflow that rarely happens. Care is measurement-based: the team tracks whether the referral resolved the need, not just whether it was made.
For patients: expect a few short questions about your daily life — food, housing, getting to appointments, safety. Answering honestly helps your care team connect you to real support. It's part of your medical care and kept under the same privacy protections as the rest of your record.
For practices: SDOH screening, Z-code documentation, and closed-loop referral are increasingly expected under value-based and Medicaid programs — but they're hard to sustain without staff to run them. Embedding collaborative care adds a care manager who can carry that work as part of routine behavioral health support, so screening actually happens and gets documented.
Z-codes are ICD-10-CM codes in the Z55–Z65 range that document social and economic circumstances affecting a patient's health — such as homelessness, food insecurity, or transportation problems. They turn a social need identified during screening into structured data the whole care team can see and act on.
No. Screening is voluntary, and answers are protected like the rest of your medical record. Sharing an unmet need simply lets the care team connect you to resources that can help; declining doesn't affect your access to care.
No. Screening is meant to be routine for all patients, not targeted at a group, because social needs cut across income and background. Routine screening also avoids assumptions about who might be affected.
Social needs and mental health are tightly linked — unmet needs like food or housing insecurity make depression and anxiety harder to treat. In collaborative care, the same care manager who tracks behavioral health symptoms also screens for social needs and coordinates referrals, so both are addressed together.
The resources come from community-based organizations, benefits programs, and local services — food assistance, housing and benefits navigation, transportation, and safety resources. The care team's job is to make the connection and follow up to confirm the need was met.
