Factoring essential needs into care efforts is not easy, but we design strategies around the full picture of what patients and communities need to be healthy. For more than 20 years, We have helped design and implement social needs navigation programs, train front-line staff to do the work effectively, identify and work closely with community organizations, and establish workflows that complement existing processes. We know that each community or healthcare organization is unique. We work collaboratively to guide and customize solutions to meet their client’s specific goals and needs — with a specific focus on: Community Health Aims – Charting a path to community health, building relationships with community-based organizations, building effective patient advisory councils; Caregivers – Developing and training a workforce, empowering local community health workers, driving caregiver sustainability; Measurement, Improvement, and Technology – Selecting social needs technology, setting and tracking measures, integration into workflow.


  • With 20 years of direct, client-facing experience addressing social determinants of health, we have the proven experience and resources to enable health systems and community partners to start and scale successful social needs initiatives.
  • We offer a broad range of expertise and support, with the flexibility to meet the needs of ACOs and CPs.
  • Our TA services are backed by:
    • Consultants who are experienced social workers and case managers, and have direct experience designing and managing SDOH initiatives
    • A national headquarters in Boston with more than half of all staff based in New England
    • A deep bench of expertise working with clinical and community partners across the Commonwealth
    • A broad network of clinical, community and patient leaders across the country who fuel program improvements and best practices
    • Flexible designs, tools and workflows designed to serve patient populations in a wide range of clinical and community settings
    • Human-centered, patient (community) approach to solution design and implementation
    • A non-profit, mission-driven and unwavering commitment to addressing unmet social needs
    • Active with a wide variety of ACO participants, both in clinical and non-clinical settings.


The transition to Accountable Care and efforts to improve the patient experience led a large health system to seek out opportunities to strengthen internal systems along with a new goal to build a coordinated, community-informed and responsive system to address the unmet social needs of their patients and families. Health Leads supported the development and implementation of a screening tool, and the development of direct referral relationships with community-based organizations. Health Leads trained staff on the new workflow and third-party software. Volume increased by 10% across all three sites in the weeks following implementation, and Health Leads continued to advise on strategies to improve workflow integration and staff adoption of the changes.

The statements in this document are made solely by Health Leads. No statement in this document should be construed as an official position of or endorsement by Abt Associates Inc. or the Massachusetts Executive Office of Health and Human Services.


Health Leads is a national non-profit organization that envisions a healthcare system that addresses all patients’ essential resource needs as a standard part of quality care. For more than 20 years, they’ve worked with leading health organizations to create sustainable, high-impact and cost-effective social needs programs that connect patients to the community-based resources they need to be healthy — from food to transportation to healthcare benefits. Since their founding in 1996, Health Leads has combined frontline experience in diverse clinical settings with proven technology, training and expertise to enable health systems to launch and scale successful social needs interventions.


We have an official mascot: the Unicorn (seriously!). In our early days in Boston, Health Leads set out to recruit our first team of leaders, individuals who had a seemingly-impossible combination of significant clinical background, on-the-ground work in communities and deep program management experience. Our first “unicorns” joined the Health Leads team way back in the 1990s, and they haven’t turned back since!


  • “Working with Health Leads was a great experience! To look at where we started and where we are now, what we were able to accomplish in three months is incredible. The guidance Health Leads has provided is amazing.” -Population Health Evaluator, Non-profit Health System
  • “In healthcare, we need to think about creative ways to bring in more resources for our patients. There are many ways to do that, but Health Leads really opened my eyes to how a broader healthcare team can provide essential healthcare services. The team is no longer just the doctor and the patient.” -Pediatric Specialist, Integrated Health System
  • “A dynamic integration of information and best practices…they equipped us with the tools to empower patients to get to the root causes of their health issues and on the path to well-being.” -Director of Services & Clinical Social Worker



Actuarial and Financial

Care Coordination/Integration

Community-Based Care and Social Determinants of Health

Consumer Engagement

Flexible Services

Health Information Technology (HIT)

Performance Improvement

Population Health Management