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Social Needs Screening and Referral Workflows

Grant to a California Individual or Organization for Research
Related to Screening for Social Needs Issues that Affect Health

Agency Type:

Foundation / Corporation

Funding Source:

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California Health Care Foundation (CHCF) - California Improvement Network (CIN)

Deadline Date:

10/26/18 Noon PT


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Grant of $15,000 to a California individual or organization for research into how California health networks screen for social needs that impact health and make referrals to address those needs. Funding is intended for the performance of several short case studies and the creation of a webinar to share the findings with other relevant professionals.

The California Improvement Network (CIN) aims to advance the Quadruple Aim by identifying and spreading better ideas for care delivery, and by strengthening relationships between commercial and safety-net providers and health plan communities in California.

CIN is focusing on five core topic areas in 2018 and 2019:
- Making improvements in behavioral health care, with an emphasis on cost management
- Addressing social needs that affect health, with an emphasis on cost management
- Understanding the fundamentals of managing financial risk and the cost of care
- Preventing burnout and promoting provider and staff resilience
- Leading change

Within the topic area of addressing social needs that affect health, with an emphasis on cost management, CIN partners have identified two specific areas where they most want programming and support to help advance their work. These two learning areas are:
1. Analyzing return on investment (ROI) in efforts to address social needs that impact health
2. Understanding leading practices and workflows for screening and referrals

This is a request for proposals (RFP) for the second area – the need to learn about leading practices and gain access to documented workflows for screening and referrals related to efforts to address social needs that impact health.

While there are existing resources for finding and assessing screening tools and referral platforms to assist with social needs efforts, it is much more challenging to find the concrete operational details of how organizations are implementing these tools. The purpose of this project is to learn from organizations that have made significant progress in screening and referring for social needs by (1) documenting the operational details of implementation and workforce changes required for screening, referrals, and cross-organization coordination, and (2) distributing these operational workflows and documented leading practices in digestible and accessible formats for use by other health care organizations.

This project will explore, record, and share examples of implementation efforts related to screening and referral for social needs. The grantee will:

- Identify and select four leading health organizations, which are of similar types to CIN partner organizations (e.g., a Federally Qualified Health Center; an independent practice association; a large, integrated health system; a health plan), that have successfully implemented screening and/or referral tools for their social needs efforts and are willing to share the operational details of their work.

- Gather documentation of workflows, such as process maps, relevant staffing models for the screening and referral work, job descriptions, etc., and other tools from the selected organizations, and interview organizations as needed to fully understand and describe their model and workflows.

- Synthesize findings into process maps or similar detailed implementation aids, with accompanying (short) case studies that contain the pertinent details of the organization. The goal of these process maps and short case studies is for other health organizations to be able to learn about and implement similar processes in their own organizations.

GrantWatch ID#:

GrantWatch ID#: 184429

Estimated Size of Grant:


Term of Contract:

Project period: November 5, 2018 – February 28, 2019

Additional Eligibility Criteria:

Organizations or individuals with demonstrated experience executing similar projects and knowledge of quality improvement, social needs that impact health, and health care operations. The ideal candidate is familiar with the California health care landscape and CIN, and has awareness of, or a clear process for identifying, leading organizations to profile for the project.

Pre-Application Information:

- Proposal due October 26, 2018 by noon PT
- Grantee selected by November 5, 2018
- Project period: November 5, 2018 – February 28, 2019
- Process maps, case studies published by February 14, 2019; webinar held by February 28, 2019

Contact Information:

Before starting your grant application, please review the funding source's website listed below for updates/changes/addendums/conferences/LOIs.

To submit the application or for questions about the application or grant administration, please contact:
Amy Quan, CIN program associate
(415) 514-2853

For questions or more information about this opportunity, please contact:
Rebecca Hargreaves, CIN program office lead
(415) 502-3296

URL for Full Text (RFP):

Geographic Focus:

USA: California