Disclaimer: This is general education—not medical, legal, or billing advice. For personal care, talk with your clinician and a licensed benefits advisor.
Food, housing, transportation, and human connection aren’t “extras.” They are core drivers of health and lifespan. This guide shows the strongest evidence, what’s new in 2025 Medicare for screening and navigation, and practical steps—so patients, clinics, and employers can address social needs and improve outcomes that matter.
Start here—what “social needs” mean and why they matter
Social determinants of health (SDOH) are the conditions where we live, learn, work, play, worship, and age that shape health risks and outcomes—grouped into five domains (economic stability; education; health care access/quality; neighborhood/built environment; social/community context). Health.gov
Why this matters: decades of research show these nonmedical conditions drive a large share of health outcomes. The CDC emphasizes that addressing SDOH can improve health, reduce longstanding inequities, and lower costs. CDC
Bottom line: You can’t separate health from daily life conditions—and those conditions are changeable through programs, benefits, and design. Health.gov
Social connection & longevity—what the evidence shows
- The U.S. Surgeon General reports that poor social connection raises premature death risk (with estimated effects comparable to smoking), and increases heart disease and stroke risk. Source: HHS, last checked: Sept 14, 2025. HHS.gov+1
- A large meta-analysis (148 studies; 308,849 people) found 50% higher survival among those with stronger social relationships—an effect size on par with other major risk factors. Source: PLOS Medicine, last checked: Sept 14, 2025. PLOS
- CDC’s 2024 analysis links loneliness/isolation to broad mental and physical health harms across U.S. adults. CDC
What to do with this: Treat social connection as a vital sign—ask about loneliness, foster group visits/peer support, and create environments (home, work, community) that make connection easy.
Bottom line: Connected people live longer—and modest design changes (group programs, warm referrals, volunteering opportunities) can strengthen that connection. PLOS+1
Do interventions work? Mixed but promising—what’s proven so far
1) Navigation to community resources lowers use and costs.
The CMS Accountable Health Communities (AHC) Model (2018–2023) screened 1.1M people and navigated those with needs. The evaluation found 3–4% lower total expenditures, fewer ED visits/inpatient stays—with larger gains for underserved groups. Source: CMS Innovation Center, last checked: Sept 14, 2025. CMS
2) Food-Is-Medicine:
- An RCT of an intensive clinic food program increased preventive-care engagement but did not improve A1c across 1 year. JAMA Network
- Produce prescriptions: systematic reviews show higher fruit/veg intake; some pilots show clinical improvements, but results vary by program design. American Heart Association Journals
- Medically tailored meals (MTMs): 2025 Health Affairs modeling projects meaningful reductions in hospitalizations and cost savings if states scale MTMs for diet-sensitive conditions (observational and modeling evidence; RCT evidence still emerging). Source: Health Affairs, last checked: Sept 14, 2025. Health Affairs
3) Home-delivered meals post-discharge (older adults).
A Medicare Advantage cohort found meal delivery associated with lower 30-day rehospitalization and mortality, suggesting a pragmatic path to better transitions. PMC
4) Housing & energy stability:
Studies link lower winter heating prices to fewer winter deaths, mostly cardiovascular/respiratory—highlighting the health value of energy assistance. Eviction research shows higher hospital use and worse mental health. PMC+1
5) Social prescribing & community programs:
Large-scale programs (e.g., NHS) and a 2025 evidence review suggest potential, but U.S. outcome evidence is still maturing; pairing navigation + access appears key. NHS England+1
Bottom line: Addressing social needs works best when paired with navigation and clinical integration; results are strongest for targeted groups and when barriers (transport, utilities, benefits) are actually removed. CMS
The 2025 toolkit for U.S. clinics (and why it matters)
Screen & document:
- SDOH Risk Assessment (HCPCS G0136)—Medicare pays once every 6 months when furnished with certain visits (including AWV). Source: CMS, last checked: Sept 14, 2025. CMS+1
- Z codes (Z55–Z65)—ICD-10-CM codes that capture social needs (e.g., Z59.0 homelessness; Z59.4 lack of adequate food; Z59.64 lack of transportation). Source: CMS, last checked: Sept 14, 2025. CMS
Act & navigate:
- Community Health Integration (CHI) codes (e.g., G0019/G0022) and Principal Illness Navigation (PIN) added in the 2024 Medicare Physician Fee Schedule; RHCs/FQHCs can bill, with further 2025 billing options expanding. Source: CMS Fact Sheet; RHIhub, last checked: Sept 14, 2025. CMS+1
Why this improves outcomes: Screening + Z-coding + reimbursable navigation closes the loop between identifying a need and resolving it—mirroring the features that drove AHC gains. CMS
Bottom line: In 2025, it’s finally feasible to screen, document, and get paid to help patients solve social barriers that derail care. CMS+1
The 2025 toolkit for U.S. clinics (and why it matters)
Screen & document:
- SDOH Risk Assessment (HCPCS G0136)—Medicare pays once every 6 months when furnished with certain visits (including AWV). Source: CMS, last checked: Sept 14, 2025. CMS+1
- Z codes (Z55–Z65)—ICD-10-CM codes that capture social needs (e.g., Z59.0 homelessness; Z59.4 lack of adequate food; Z59.64 lack of transportation). Source: CMS, last checked: Sept 14, 2025. CMS
Act & navigate:
- Community Health Integration (CHI) codes (e.g., G0019/G0022) and Principal Illness Navigation (PIN) added in the 2024 Medicare Physician Fee Schedule; RHCs/FQHCs can bill, with further 2025 billing options expanding. Source: CMS Fact Sheet; RHIhub, last checked: Sept 14, 2025. CMS+1
Why this improves outcomes: Screening + Z-coding + reimbursable navigation closes the loop between identifying a need and resolving it—mirroring the features that drove AHC gains. CMS
Bottom line: In 2025, it’s finally feasible to screen, document, and get paid to help patients solve social barriers that derail care. CMS+1
For patients & caregivers—who to call and what to ask
- Dial 211 (or visit 211.org) for local food, housing, transportation, and utility help.
- SNAP & senior nutrition: Apply for SNAP; ask about home-delivered meals via your Area Agency on Aging (AAA). Source: ACL OAA nutrition & Meals on Wheels research, last checked: Sept 14, 2025. ACL Administration for Community Living+1
- Energy bills: Ask your utility or local agency about LIHEAP—energy help is a health intervention in winter. PMC
- Transportation: Ask your plan/clinic about medical ride benefits; many Medicare Advantage and Medicaid plans include non-emergency medical transport.
- Social connection: Try local senior centers, libraries, faith groups, volunteer roles, or phone-based “friendly caller” programs; ask your clinician about group visits or community classes.
Bottom line: One call (211/AAA) can unlock multiple supports—food today, a ride tomorrow, and someone to check in weekly.
For employers & health plans—benefits that move the needle
- Transit & rides: Offer or reimburse transit/ride-share to medical visits.
- Social connection by design: Sponsor employee clubs, volunteer days, mentor programs; measure belonging in pulse surveys.
- Caregiving supports: Paid leave and backup eldercare reduce crisis-driven absenteeism and stress-related health risks.
- Food benefits: Grocer/gift-card stipends tied to diet-sensitive conditions; partner with MTM vendors for high-risk members (evaluate outcomes). Health Affairs
Bottom line: Benefits that target transport, food, and connection can lower downstream medical use—especially in high-risk populations. CMS
Comparison table—how to address social needs (who does what)
| Pathway | Who leads | What it does | How it helps outcomes |
|---|---|---|---|
| Clinical screening (G0136) | Clinician team | Standardized SDOH assessment during visit | Turns “unknown needs” into documented problems you can solve. CMS |
| Z-code documentation | Billing/coding + clinicians | Adds SDOH to the chart (Z55–Z65) | Enables navigation, tracking, and population analytics. CMS |
| Community Health Integration (CHI/PIN) | CHWs/navigators | Monthly help to connect to food, housing, transport | Mirrors AHC components that cut ED/inpatient use. CMS+1 |
| Food supports (SNAP/MTM/produce Rx) | Plans + CBOs | Benefits + delivered meals or produce | Evidence mixed; intake improves; modeling shows potential cost/hospitalization reductions at scale. American Heart Association Journals+1 |
| Post-discharge meals | Plans + CBOs | Meals for 2–12 weeks post-hospital | Linked to fewer 30-day rehospitalizations/mortality in older adults. PMC |
| Energy/utility assistance (LIHEAP) | States/utilities | Keeps homes heated/cooled | Lower winter mortality—especially cardiopulmonary. PMC |
| Social prescribing / group programs | Clinics + community | Link to classes, volunteering, clubs | Improves connection; outcome evidence rising. PMC |
7-step screen-and-act checklist (print-ready)
- Ask briefly, act deeply. Use a short SDOH tool; if positive, warm-handoff to navigation (CHI/PIN). Source: CMS PFS 2024, last checked: Sept 14, 2025. CMS
- Code it. Add the appropriate Z codes for food, housing, utilities, transport, or social isolation. CMS
- Prioritize safety & stability. Address urgent risks (eviction, heat shut-off, food today) first; coordinate with 211/AAA.
- Link to benefits. SNAP, LIHEAP, rental help, rides—help complete forms during the visit when possible.
- Close the loop. Confirm the referral was received and scheduled; document barriers and next steps.
- Measure what matters. Track ED visits, inpatient days, A1c/BP, and loneliness scales at baseline and follow-up.
- Reassess every 6 months (or sooner after major life changes). Bill G0136 when eligible. Source: CMS, last checked: Sept 14, 2025. CMS
Bottom line: Screen → code → navigate → verify. Revisit needs regularly; life changes fast.
Evidence callouts you can cite on your site/materials
- “50% higher survival” with stronger social relationships. Source: PLOS Medicine meta-analysis, last checked: Sept 14, 2025. PLOS
- Loneliness raises heart disease (29%) and stroke (32%) risk. Source: Surgeon General/HHS, last checked: Sept 14, 2025. HHS.gov
- AHC navigation cut costs 3–4% and ED/inpatient use. Source: CMS Innovation Center, last checked: Sept 14, 2025. CMS
- Lower winter heating prices → fewer deaths. Source: 2023 heating-price/mortality study, last checked: Sept 14, 2025. PMC
- Medicare pays for SDOH assessment (G0136) and CHI/PIN services. Source: CMS PFS 2024/2025 updates, last checked: Sept 14, 2025. CMS+1
FAQs
What are the social determinants of health (SDOH)?
They’re the conditions where people live, learn, work, play, worship, and age that affect health—across five domains (economic, education, health care, neighborhood/built environment, social/community). Health.gov
Does addressing social needs really improve outcomes?
Yes—navigation programs (e.g., AHC) reduced spending and ED/inpatient use, and home-delivered meals after hospital discharge were associated with lower 30-day readmissions and mortality in older adults. Results are strongest when needs are resolved, not just screened. CMS+1
Can Medicare pay for SDOH screening and navigation?
Yes. In 2024, Medicare added G0136 (SDOH risk assessment) and Community Health Integration (CHI)/PIN services; RHCs/FQHCs can bill, with 2025 billing pathways expanding. CMS+1
What are SDOH “Z codes,” and why use them?
ICD-10-CM Z55–Z65 capture social needs (e.g., food, housing). They help teams coordinate care, support benefits referrals, and track outcomes. CMS
Does loneliness really affect longevity?
Yes. Stronger social relationships are linked to 50% higher survival odds; poor connection increases risks for heart disease and stroke. PLOS+1
Are “Food-Is-Medicine” programs proven?
They improve diet quality and may reduce hospital use and costs—especially medically tailored meals—but RCT results are mixed; program design and intensity matter. American Heart Association Journals+2Health Affairs+2
3–5 takeaways & next steps
Takeaways
- Connection is medicine: stronger social ties correlate with longer life. PLOS
- Navigation works: screening and helping people connect lowers ED/inpatient use and spending. CMS
- Medicare now pays for SDOH assessment (G0136) and CHI/PIN navigation—use them. CMS+1
- Target the basics: food, housing/energy, transport—these have measurable health impacts. PMC
Next steps
- Clinics: adopt a screen-code-navigate workflow; track outcomes quarterly.
- Patients/caregivers: call 211 and your Area Agency on Aging; ask your clinician about meals, rides, and connection groups.
- Employers/plans: fund transport, caregiving, and connection; pilot post-discharge meals and measure 30-day returns. PMC