You screened the patient. The survey flagged food insecurity, an unreliable car, a utility shut-off notice — a real barrier sitting underneath the A1c that will not come down. You documented it, maybe even coded it. Then the visit ended, the patient went home, and the need went exactly nowhere. Screening found the problem. Nothing solved it.
That gap — between identifying a social need and actually closing it — is the most expensive dead end in value-based care. And for most practices, the tool that closes it is one click away inside a platform you already use.
Screening Without a Referral Is a Dead End
Non-Medical Drivers of Health (NMDOH), the broader framing for what most of us still call Social Determinants of Health (SDOH), are the upstream lever on nearly every quality measure you are chasing. Transportation gaps cause missed visits. Food insecurity drives uncontrolled diabetes. Housing instability undercuts medication adherence. As EH’s own guidance puts it plainly, people with unmet social needs are less likely to access the healthcare they need, even when it is available [1].
Screening is now standard practice. Several validated tools are in common use — Equality Health’s Health Access Survey, PRAPARE (the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences), and the CMS Accountable Health Communities Health-Related Social Needs screening tool [1]. Most practices administer one at the annual well visit — or fold it into the annual paperwork — and document the result in the EHR with supplemental Z-codes [1]. That is the right start. But a screen that ends in a Z-code and nothing else is a diagnosis with no treatment. The need was named, then abandoned.
The Two Lanes Behind One Button
Inside CareEmpower®, the FindHelp CareEmpower social care referral workflow lives behind a single Referral button at the top-right of the main panel [2]. Click it and two lanes open — and knowing which to use is the whole game.
Lane one: the FindHelp self-serve directory
The first lane is a searchable directory of free and reduced-cost community services — food pantries, housing assistance, transportation, utility help, behavioral health — filterable by ZIP code [2]. This is your fast lane for a concrete, bounded need — a food bank this week, a ride to next month’s appointment, the lights kept on. Say a social-needs screen at a diabetic patient’s annual visit surfaces food insecurity: instead of stopping at documentation, open the Referral button, drop into the FindHelp directory, and pull two food resources in her ZIP code before she leaves the room — then capture the finding with the relevant Z-code submitted alongside your CPT II code (Z-codes are supplemental reporting codes, not a primary diagnosis) [1]. There is also a co-branded member-facing instance at equalityhealth.findhelp.com, so members can search resources themselves between visits. For straightforward needs, self-serve is faster than waiting on a callback.
Lane two: the warm hand-off to EH Care Specialists
The second lane, reached through the same button, is a referral to EH Care Specialists for extended support [3]. Use it when the need is layered or the patient cannot navigate it alone — a high-risk member missing visits because transportation, a utility crisis, and a behavioral health concern have all landed at once. A directory link will not hold that. You send a referral with notes — preferred language, best time to call, a caregiver’s number — and our Community Health Workers (CHWs) and Care Specialists pick up the navigation, coordination, and follow-through that a link cannot carry on its own [3]. This is the difference between handing a patient a phone number and handing their need to someone who will answer it.
How the loop actually closes
A referral you cannot track is just a hand-off into the dark. This lane closes the loop. When you submit a care-coordination referral, you set an urgency: Priority carries a 4-to-7-day response, Routine an 8-to-14-day response [3]. Feedback on referral activity comes back through CareEmpower directly, and you can read it in the Patient Profile Referrals tab — per patient, or across your whole practice [3]. That is the difference between hoping a need got met and knowing it did.
What Closing the Loop Looks Like
When the loop closes, the downstream effects are the ones you are already measured on. EH’s operating thesis is direct: by connecting patients to community resources and tackling the root causes of nonadherence, practices see higher medication compliance, fewer avoidable ED visits, and measurable improvements in chronic condition control [4]. The screened need that used to evaporate now has a documented path, a response window, and a result you can see.
The Question Isn’t Whether You Can Help. It’s Whether You’ll Click.
The FindHelp CareEmpower social care referral workflow is not a new program to stand up — it is a button already in the platform on your screen, with two lanes that often go unused. One routes a bounded need to a local resource in seconds. The other hands a complex one to a Care Specialist who will carry it. Both feed results back to your Referrals tab. The next time a screen surfaces a social need, the question is not whether you can do something about it. It is whether you will click the button that already can.
References
[1] Equality Health. SDOH Quality Guide (March 2025). Screening tools; Z-codes as supplemental reporting codes submitted alongside CPT II.
[2] Equality Health. Screening for Social Determinants of Health — Pathways to Better (June 2025). Referral button → FindHelp directory and EH Care Specialist lanes.
[3] Equality Health. CareEmpower® User Guide (February 2026), pp. 37–43. Care-coordination referral form; Priority/Routine response windows; feedback through CareEmpower; Patient Profile Referrals tab.
[4] Equality Health. Screening for Social Determinants of Health — Pathways to Better (June 2025). Outcomes framing: medication compliance, fewer avoidable ED visits, chronic-condition control.
