Addressing Social Needs to Build Healthier Communities

October 09, 2026

HAP’s Caring for the Commonwealth series showcases the innovative programs led by Pennsylvania hospitals and health systems—and, most importantly, the difference they make for communities. The series brings these stories to life, highlighting how our members are improving health and creating stronger, healthier communities.

Building healthier communities in low-income areas starts with understanding the challenges residents face before they lead to serious health problems. Housing instability, food insecurity, transportation barriers, financial pressures, and limited access to care can all contribute to health disparities and make it harder for people to stay healthy.

Rather than waiting until these challenges take a toll on a patient’s health, Temple Health has developed a comprehensive approach to identifying social needs and connecting patients and community members with meaningful resources and support.

Since 2019, Temple has expanded its Social Drivers of Health (SDOH) screening initiative across primary care, emergency departments, and specialty settings, demonstrating a strong commitment to addressing the impact of social drivers of health on overall health outcomes. During this period, Temple Health has completed more than 850,000 screenings, helping to identify barriers related to housing, food security, transportation, financial stability, and access to care according to Lakisha R. Sturgis, RN, BSN, MPH, CPHQ, Director of Community Care Management, Population Health for Temple Health. These efforts have supported the organization’s population health strategy by enabling earlier intervention, strengthening care coordination, connecting individuals to community resources, and improving the ability to address non-medical factors that influence health and well-being.

The initiative goes beyond screening by building a network of community partnerships and developing programs tailored to local needs. Community health workers recruited from the community help patients access resources, while specialized programs address food and housing insecurity, transportation, digital access, and other barriers to health.

The health system also created an intensive clinic for patients with complex medical and social needs and expanded outreach into the community through a mobile health van and community events. The result is a model that demonstrates how health systems can serve as community partners—not simply places where people receive medical care—and translate identification of social needs into measurable improvements in health, Sturgis said.

Here are a few key takeaways:

• Identifying community needs:  More than 40 percent of residents in the surrounding community live in poverty, with food insecurity, housing, violence, and access to care identified as major concerns.
• Large-scale screening:  SDOH screening expanded from 9,800 screenings in 2019 to more than 245,000 in 2025.
• Addressing food and housing insecurity:  Programs include a hospital food pantry, partnerships providing fresh produce to families, temporary housing, and assistance with urgent housing-related needs.
• Targeted care:  The Multi-Visit Patient (MVP) Clinic provides intensive medical and social support to patients with complex needs and frequent hospital use.
• Improved outcomes:  Patients served by the MVP Clinic experienced 58 percent fewer hospitalizations and 55 percent fewer emergency department visits, while increasing outpatient visits by 35 percent.
• A lesson for other communities:  The program demonstrates that screening works best when health systems have meaningful resources and partnerships in place to respond to what patients disclose.

HAP's Caring for the Commonwealth series presents impactful programs led by our members. If you have an interesting story to share, please contact Kim Yakowski, HAP’s manager, media relations.