Glossary

SDOH Clinical Care, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-sdoh-clinicalcare/ and changes regularly. See the Directory of published versions

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Term	Definition	References
Social determinants of health (SDOH)	The conditions in which people are born, grow, live, work and age, and people's access to power, money and resources (Equivalent to social drivers of health)	World Health Organization. (n.d.). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 World Health Organization. (2010). A conceptual framework for action on the social determinants of health. https://www.who.int/publications/i/item/9789241500852
Standardized assessment instrument	An evaluation or measurement instrument, often in a scale or questionnaire form, that is valid and reliable, and replicable without changes or adaptations in its structure and content.	Rodríguez-Violante, M., Hernández-Medrano, A. J., & Cervantes-Arriaga, A. (2024). The importance of standardized assessment. Movement Disorders Clinical Practice, 11(Suppl. 3), S15–S20. https://doi.org/10.1002/mdc3.14085
Social risk	Adverse social conditions associated with poor health. (Equivalent to health-related social needs, or HRSN)	Adapted from: Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinants of health lexicon for health care systems. The Milbank Quarterly, 97(2), 407–419. https://doi.org/10.1111/1468-0009.12390
Social need	Patient-prioritized social risks	Adapted from: Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinants of health lexicon for health care systems. The Milbank Quarterly, 97(2), 407–419. https://doi.org/10.1111/1468-0009.12390
Protective factor	Characteristics or strengths of individuals, families, communities or societies that act to mitigate risks and promote positive well-being and healthy development	Center for the Study of Social Policy. (2025). About Strengthening Families™ and the Protective Factors Framework. https://cssp.org/wp-content/uploads/2025/03/About-Strengthening-Families.pdf
Holistic assessment	A robust, comprehensive assessment of social, physical, emotional, and ecosystem context to identify risks, needs, strengths, and supports toward the aim of establishing priorities and goals.	Gravity Project, & Civitas Networks for Health. (2024). Social care co-design: Final report. Civitas Networks for Health. https://www.civitasforhealth.org/wp-content/uploads/2024/02/FINAL-Co-Design-Report-Gravity-Project-and-Civitas-Networks-for-Health.pdf
Biopsychosocial–spiritual assessment	Biopsychosocial–spiritual assessment is a fundamental process of social work practice in health care settings. The foundation of client care planning is the comprehensive assessment, which requires social workers to engage clients in identifying their needs and strengths and supporting clients in establishing priorities and goals. In conducting an assessment, the health care social worker must use empathy, client-centered interviewing skills, and methods appropriate to clients' capacity. In the assessment process, social workers may find standardized instruments helpful in identifying and responding to client concerns. Such instruments are viewed as starting points in the development and refinement of an individualized, comprehensive assessment.	National Association of Social Workers. (2016). NASW standards for social work practice in health care settings. https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/NASW-Standards-for-Social-Work-Practice-in-Health-Care-Settings
Biopsychosocial–spiritual perspective	A biopsychosocial–spiritual perspective recognizes the importance of whole person care and takes into account a client's physical or medical condition; emotional or psychological state; socioeconomic, sociocultural, and sociopolitical status; and spiritual needs and concerns.	National Association of Social Workers. (2016). NASW standards for social work practice in health care settings. https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/NASW-Standards-for-Social-Work-Practice-in-Health-Care-Settings
Business associate	A "business associate" is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. A member of the covered entity's workforce is not a business associate.	Adapted from: Landauer, R., & Downer, S. (2022, January). HIPAA issue brief 4 of 5: Business associate arrangements. Center for Health Law and Policy Innovation of Harvard Law School; GusNIP NTAE Center, Nutrition Incentive Hub. https://chlpi.org/wp-content/uploads/2022/02/hipaa-brief-4.pdf U.S. Department of Health and Human Services, Office for Civil Rights. (2019, May 24). Business associates. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html
Care coordinator	One who organizes an individual's care across multiple providers.	Adapted from: Agency for Healthcare Research and Quality. (2024, November). Care coordination. U.S. Department of Health and Human Services. https://www.ahrq.gov/ncepcr/care/coordination.html
Community-based organization (CBO)	A public or private nonprofit organization that is representative of a community or a significant segment of a community and works to meet community needs. Ideally, Community-Based Organizations are driven by community residents in all aspects, aligned with the principles of the National Community-Based Organization Network.	National Community-Based Organization Network. (2004). What is a CBO? University of Michigan School of Public Health. https://sph.umich.edu/ncbon/about/whatis.html National Institutes of Health. (n.d.). Community-based organization (CBO). HIV.gov Clinical Info Glossary. https://clinicalinfo.hiv.gov/en/glossary/community-based-organization-cbo
Coordination platform (CP) (aka community resource referral platform)	A technology platform that enables health care organizations to identify, search, and electronically refer patients to community-based social service organizations in order to address unmet social needs. Some community resource referral platforms also enable self-referral.	Adapted from: Cartier, Y., Fichtenberg, C., & Gottlieb, L. (2019, April 16). Community resource referral platforms: A guide for health care organizations. Social Interventions Research & Evaluation Network (SIREN), University of California, San Francisco. https://sirenetwork.ucsf.edu/sites/default/files/wysiwyg/Community-Resource-Referral-Platforms-Guide.pdf
Patient navigation	Navigation is a patient-centric healthcare service delivery model. The focus of navigation is to promote the timely movement of an individual patient through an often complex healthcare continuum. The core function of navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.	Freeman, H. P., & Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117(15 Suppl), 3537–3540. https://doi.org/10.1002/cncr.26262
Community resource navigator	A professional who connects people with the resources they need to thrive. This includes assistance with housing, transportation, healthcare, education, and more. They work with community organizations and government agencies to identify and connect people with the services that can best meet their needs. They are often the first point of contact for people seeking assistance, and must be able to assess needs, provide information and referrals, and advocate for the client.	Adapted from: National Association of Social Workers Washington. (n.d.). Community resource navigator overview. https://careers.naswwa.socialworkers.org/career/community-resource-navigator
Covered entity	Covered entities are defined in the HIPAA rules as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.	Adapted from: U.S. Department of Health and Human Services, Office for Civil Rights. (2024, August 21). Covered entities and business associates. https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html
Patient	A consumer, or client, who is the subject of care, including assessment, goal identification, referrals, and service provision. Use of the term in this IG does not necessarily imply a clinical context.
Provider	Includes licensed providers and qualified professionals who interact with the patient to assess social risks, set goals, and determine/recommend referrals.
SDOH domain	An area of activity describing one of the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
Closed system	A system in which the referral source, intermediary, and referral target all use the same system or platform. In this environment, capacity status, if shared, is known without the need for a standards-based exchange. Closed systems are out of scope for this guide.
Open system	A system in which the referral source, intermediary, and referral target each use disparate systems that cannot natively interoperate. To share information like capacity status, an agreed-upon exchange method (e.g., FHIR) is required. Open systems are in scope.
Hybrid system	A system in which some trading partners use the same system, while others use different systems. An agreed-upon exchange method (e.g., FHIR) is still necessary to communicate capacity status across the disparate system boundaries. Hybrid systems are in scope.
Direct referral	A referral between a referral source (e.g., health care provider) and a referral target (e.g., a social service organization such as a CBO) where both entities have FHIR server APIs and an intermediary using a coordination platform (CP) is not involved in the referral.
Indirect referral	A referral between a referral source (e.g., health care provider) and a referral target (e.g., a social service organization such as a CBO) that involves an intermediary using a coordination platform (CP) and all entities have FHIR server APIs.
Electronic health record system	A set of technical components — including rules and procedures, processing and storage devices, and communication and support facilities — whose core function is to capture, store, retrieve, display, and exchange health-related information across authorized users, settings, and systems.	Adapted from: Office of the National Coordinator for Health Information Technology. (2026, May 7). Base electronic health record (EHR) definition. U.S. Department of Health & Human Services. https://healthit.gov/certification-health-it/certification-criteria/base-electronic-health-record-definition/ Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care (Rev. ed.). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK233055/ Healthcare Information and Management Systems Society. (n.d.). Electronic health records. https://www.himss.org/library/ehr U.S. Code, 42 U.S.C. § 17921(5). https://www.law.cornell.edu/uscode/text/42/17921#5 International Organization for Standardization. (2011). Health informatics — Requirements for an electronic health record architecture (ISO 18308:2011). https://www.iso.org/standard/52823.html
Intermediary	An organizational actor that sits between a referral source and a referral target to facilitate and coordinate the referral (for example, a community care hub). It typically operates a coordination platform (CP) — the system actor that relays data between the source's and target's system actors — though some intermediaries instead coordinate referrals manually (e.g., by email or spreadsheet) rather than through a CP.
Care coordination	Deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.	Agency for Healthcare Research and Quality. (2024, November). Care coordination. U.S. Department of Health and Human Services. https://www.ahrq.gov/ncepcr/care/coordination.html
Capacity	A social service organization's (e.g., a CBO's) ability to accept and serve a new individual for a social care service it offers. In this guide, capacity is a point-in-time judgment of whether the social service organization can take on a new referral for that service — separate from whether the individual later meets the service's eligibility criteria.
Capacity status	A coded indication, checked before a referral is sent, of whether a social service organization (e.g., a CBO) currently has the capacity to accept a new individual for a social care service (for assessment, or for a specific program or service). A response indicating available capacity does not guarantee eligibility or enrollment. See the SDOHCC Capacity Status value set for the allowed states.
Referral source	An organizational actor that initiates a referral to address an individual's social need (for example, a health care provider; or, in self-referral, the organization operating the community resource referral platform the individual uses to refer themselves). It operates the system actor that sends the referral and receives its status and results back.
Referral target	An organizational actor that receives a referral and has the resources to act on it by delivering — or, if it cannot, declining — the requested service or assessment (for example, a social service organization such as a CBO). It operates the system actor that receives the referral and returns its status and results.
Accountable community for health	A multisector, community-based partnerships that bring together health care, public health, social services, other local partners, and residents to address the unmet health and social needs of the individuals and communities they serve	Adapted from: California Accountable Communities for Health Initiative. (n.d.). The fundamentals. https://www.cachi.org/fundamentals
Backbone organization	Backbone organizations, critical to the work of multisector collaboratives and accountable communities for health, work with partner organizations and community members to translate a common agenda into tangible activities that partners and community members can implement to reach the goal set by the partners and community members. The Backbone Organizations help maintain overall strategic coherence and coordinates and manages the day-to-day operations and implementation of work, including stakeholder engagement, communications, data collection and analysis, and other responsibilities.	Adapted from: Breslau, J., Rasmussen, P. W., Qureshi, N., & Peet, E. D. (2023, November). Community care hubs: A promising model for health and social care coordination. Office of the Assistant Secretary for Planning and Evaluation & Administration for Community Living, U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf Population Health Innovation Lab. (2023, June 14). Backbone organization. https://pophealthinnovationlab.org/data-walk/backbone-organization/ U.S. Department of Health and Human Services. (n.d.). HHS call to action: Addressing health-related social needs in communities across the nation. https://aspe.hhs.gov/sites/default/files/documents/54c9bfde7090c3d3f02a9fd924cb3e4a/hhs-call-to-action-health-related-social-needs.pdf
Community care hub	A type of backbone organization. Nonprofit organizations that provide a centralized administrative and operational interface between health care institutions and a network of CBOs that provide social services.	Breslau, J., Rasmussen, P. W., Qureshi, N., & Peet, E. D. (2023, November). Community care hubs: A promising model for health and social care coordination. Office of the Assistant Secretary for Planning and Evaluation & Administration for Community Living, U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf
Social care network (SCN)	An outgrowth of the accountable health communities model, social care networks are coalitions of community-based organizations and health care providers connected through a common community resource referral platform to enable sustainable partnerships and efficient, measurable outcomes related to SDOH.	Adapted from: Galper, K., Miguel, C., LeJeune, K., Rung, J. M., Eddy, B., Kale, A., Schano, M., & Brignone, E. (2026). Design and early evaluation of a social care network's impact on health care costs. Health Affairs Scholar, 4(3), qxag051. https://doi.org/10.1093/haschl/qxag051
Community information exchange	A community-governed infrastructure that enables information to be effectively and responsibly shared among many organizations, using different, interoperable technologies, in support of holistic coordination of care and equitable systems change.	Kalinowski, A. G., Sorenson, P., & Johnson, B. H. (2025). Right-sizing technology for your community information exchange: A practical guide to connecting social service data systems [Report]. 211 San Diego/CIE. https://ciesandiego.org/wp-content/uploads/2025/10/CIE-Tech-Toolkit-Digital-Final-Part-1-2025.pdf Sorenson, P., & Bloom, G. (2021, October). Tackling data dilemmas in social care coordination: Pursuing open and equitable infrastructure across a fragmented health and social service landscape [White paper]. St. Louis Regional Data Alliance at the University of Missouri–St. Louis; Data Across Sectors for Health. https://stldata.org/wp-content/uploads/2021/10/Social-Care-Data-Whitepaper-October-2021.pdf
Social service organization	An organization that works to address fundamental human needs in the community and promote social well-being.	Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25(1), 2234. https://doi.org/10.1186/s12889-025-23419-3 U.S. Department of Health & Human Services. (n.d.). Social services. https://www.hhs.gov/programs/social-services/index.html Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems Stanford Medicine. (2022, June 9). Connecting health care and social services. https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations. https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0 Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance. https://doi.org/10.1080/23303131.2026.2619153
Social service program	A program with the mission to address fundamental human needs and improve the well-being of individuals, families, and/or communities.	U.S. Department of Health & Human Services. (n.d.). Social services. https://www.hhs.gov/programs/social-services/index.html Systems for Action. (2025, May 7). Frequently asked questions. https://systemsforaction.org/frequently-asked-questions Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems
Health care organization	Health care organizations are organizations that provide health care services to individuals, including hospitals, nursing care facilities, home health agencies, and clinics. Health care organizations can be organized as governmental, not-for-profit, or commercial entities. If the health care entity is financially accountable to a primary government, it could be classified as a component unit of the government.	Becker. (n.d.). Health care organizations definition. https://www.becker.com/accounting-terms/health-care-organizations
Health program	A structured series of actions and strategies designed to maintain, promote, or improve the health of individuals, communities, or populations
Public health organization	An organization that works to create the conditions in which people can live healthy lives, including activities to prevent disease and injury and promote health for the population at large. They include governmental public health agencies working at local, state, and federal levels, as well as nongovernmental organizations that contribute to the performance of core public health functions. A defining feature of public health systems is their focus on actions designed to protect and improve health at a population level rather than purely at an individual level through the delivery of personal health services.	Adapted from: Systems for Action. (2025, May 7). Frequently asked questions. https://systemsforaction.org/frequently-asked-questions

Term

Definition

References

Social determinants of health (SDOH)

The conditions in which people are born, grow, live, work and age, and people's access to power, money and resources (Equivalent to social drivers of health)

World Health Organization. (n.d.). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

World Health Organization. (2010). A conceptual framework for action on the social determinants of health. https://www.who.int/publications/i/item/9789241500852

Standardized assessment instrument

An evaluation or measurement instrument, often in a scale or questionnaire form, that is valid and reliable, and replicable without changes or adaptations in its structure and content.

Rodríguez-Violante, M., Hernández-Medrano, A. J., & Cervantes-Arriaga, A. (2024). The importance of standardized assessment. Movement Disorders Clinical Practice, 11(Suppl. 3), S15–S20. https://doi.org/10.1002/mdc3.14085

Social risk

Adverse social conditions associated with poor health. (Equivalent to health-related social needs, or HRSN)

Adapted from: Alderwick, H., & Gottlieb, L. M. (2019). Meanings and misunderstandings: A social determinants of health lexicon for health care systems. The Milbank Quarterly, 97(2), 407–419. https://doi.org/10.1111/1468-0009.12390

Social need

Patient-prioritized social risks

Protective factor

Characteristics or strengths of individuals, families, communities or societies that act to mitigate risks and promote positive well-being and healthy development

Center for the Study of Social Policy. (2025). About Strengthening Families™ and the Protective Factors Framework. https://cssp.org/wp-content/uploads/2025/03/About-Strengthening-Families.pdf

Holistic assessment

A robust, comprehensive assessment of social, physical, emotional, and ecosystem context to identify risks, needs, strengths, and supports toward the aim of establishing priorities and goals.

Gravity Project, & Civitas Networks for Health. (2024). Social care co-design: Final report. Civitas Networks for Health. https://www.civitasforhealth.org/wp-content/uploads/2024/02/FINAL-Co-Design-Report-Gravity-Project-and-Civitas-Networks-for-Health.pdf

Biopsychosocial–spiritual assessment

Biopsychosocial–spiritual assessment is a fundamental process of social work practice in health care settings. The foundation of client care planning is the comprehensive assessment, which requires social workers to engage clients in identifying their needs and strengths and supporting clients in establishing priorities and goals. In conducting an assessment, the health care social worker must use empathy, client-centered interviewing skills, and methods appropriate to clients' capacity. In the assessment process, social workers may find standardized instruments helpful in identifying and responding to client concerns. Such instruments are viewed as starting points in the development and refinement of an individualized, comprehensive assessment.

National Association of Social Workers. (2016). NASW standards for social work practice in health care settings. https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/NASW-Standards-for-Social-Work-Practice-in-Health-Care-Settings

Biopsychosocial–spiritual perspective

A biopsychosocial–spiritual perspective recognizes the importance of whole person care and takes into account a client's physical or medical condition; emotional or psychological state; socioeconomic, sociocultural, and sociopolitical status; and spiritual needs and concerns.

Business associate

A "business associate" is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. A member of the covered entity's workforce is not a business associate.

Adapted from: Landauer, R., & Downer, S. (2022, January). HIPAA issue brief 4 of 5: Business associate arrangements. Center for Health Law and Policy Innovation of Harvard Law School; GusNIP NTAE Center, Nutrition Incentive Hub. https://chlpi.org/wp-content/uploads/2022/02/hipaa-brief-4.pdf

U.S. Department of Health and Human Services, Office for Civil Rights. (2019, May 24). Business associates. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html

Care coordinator

One who organizes an individual's care across multiple providers.

Adapted from: Agency for Healthcare Research and Quality. (2024, November). Care coordination. U.S. Department of Health and Human Services. https://www.ahrq.gov/ncepcr/care/coordination.html

Community-based organization (CBO)

A public or private nonprofit organization that is representative of a community or a significant segment of a community and works to meet community needs. Ideally, Community-Based Organizations are driven by community residents in all aspects, aligned with the principles of the National Community-Based Organization Network.

National Community-Based Organization Network. (2004). What is a CBO? University of Michigan School of Public Health. https://sph.umich.edu/ncbon/about/whatis.html

National Institutes of Health. (n.d.). Community-based organization (CBO). HIV.gov Clinical Info Glossary. https://clinicalinfo.hiv.gov/en/glossary/community-based-organization-cbo

Coordination platform (CP) (aka community resource referral platform)

A technology platform that enables health care organizations to identify, search, and electronically refer patients to community-based social service organizations in order to address unmet social needs. Some community resource referral platforms also enable self-referral.

Adapted from: Cartier, Y., Fichtenberg, C., & Gottlieb, L. (2019, April 16). Community resource referral platforms: A guide for health care organizations. Social Interventions Research & Evaluation Network (SIREN), University of California, San Francisco. https://sirenetwork.ucsf.edu/sites/default/files/wysiwyg/Community-Resource-Referral-Platforms-Guide.pdf

Patient navigation

Navigation is a patient-centric healthcare service delivery model. The focus of navigation is to promote the timely movement of an individual patient through an often complex healthcare continuum. The core function of navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.

Freeman, H. P., & Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117(15 Suppl), 3537–3540. https://doi.org/10.1002/cncr.26262

Community resource navigator

A professional who connects people with the resources they need to thrive. This includes assistance with housing, transportation, healthcare, education, and more. They work with community organizations and government agencies to identify and connect people with the services that can best meet their needs. They are often the first point of contact for people seeking assistance, and must be able to assess needs, provide information and referrals, and advocate for the client.

Adapted from: National Association of Social Workers Washington. (n.d.). Community resource navigator overview. https://careers.naswwa.socialworkers.org/career/community-resource-navigator

Covered entity

Covered entities are defined in the HIPAA rules as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.

Adapted from: U.S. Department of Health and Human Services, Office for Civil Rights. (2024, August 21). Covered entities and business associates. https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html

Patient

A consumer, or client, who is the subject of care, including assessment, goal identification, referrals, and service provision. Use of the term in this IG does not necessarily imply a clinical context.

Provider

Includes licensed providers and qualified professionals who interact with the patient to assess social risks, set goals, and determine/recommend referrals.

SDOH domain

An area of activity describing one of the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

Closed system

A system in which the referral source, intermediary, and referral target all use the same system or platform. In this environment, capacity status, if shared, is known without the need for a standards-based exchange. Closed systems are out of scope for this guide.

Open system

A system in which the referral source, intermediary, and referral target each use disparate systems that cannot natively interoperate. To share information like capacity status, an agreed-upon exchange method (e.g., FHIR) is required. Open systems are in scope.

Hybrid system

A system in which some trading partners use the same system, while others use different systems. An agreed-upon exchange method (e.g., FHIR) is still necessary to communicate capacity status across the disparate system boundaries. Hybrid systems are in scope.

Direct referral

A referral between a referral source (e.g., health care provider) and a referral target (e.g., a social service organization such as a CBO) where both entities have FHIR server APIs and an intermediary using a coordination platform (CP) is not involved in the referral.

Indirect referral

A referral between a referral source (e.g., health care provider) and a referral target (e.g., a social service organization such as a CBO) that involves an intermediary using a coordination platform (CP) and all entities have FHIR server APIs.

Electronic health record system

A set of technical components — including rules and procedures, processing and storage devices, and communication and support facilities — whose core function is to capture, store, retrieve, display, and exchange health-related information across authorized users, settings, and systems.

Adapted from: Office of the National Coordinator for Health Information Technology. (2026, May 7). Base electronic health record (EHR) definition. U.S. Department of Health & Human Services. https://healthit.gov/certification-health-it/certification-criteria/base-electronic-health-record-definition/

Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care (Rev. ed.). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK233055/

Healthcare Information and Management Systems Society. (n.d.). Electronic health records. https://www.himss.org/library/ehr

U.S. Code, 42 U.S.C. § 17921(5). https://www.law.cornell.edu/uscode/text/42/17921#5

International Organization for Standardization. (2011). Health informatics — Requirements for an electronic health record architecture (ISO 18308:2011). https://www.iso.org/standard/52823.html

Intermediary

An organizational actor that sits between a referral source and a referral target to facilitate and coordinate the referral (for example, a community care hub). It typically operates a coordination platform (CP) — the system actor that relays data between the source's and target's system actors — though some intermediaries instead coordinate referrals manually (e.g., by email or spreadsheet) rather than through a CP.

Care coordination

Deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

Agency for Healthcare Research and Quality. (2024, November). Care coordination. U.S. Department of Health and Human Services. https://www.ahrq.gov/ncepcr/care/coordination.html

Capacity

A social service organization's (e.g., a CBO's) ability to accept and serve a new individual for a social care service it offers. In this guide, capacity is a point-in-time judgment of whether the social service organization can take on a new referral for that service — separate from whether the individual later meets the service's eligibility criteria.

Capacity status

A coded indication, checked before a referral is sent, of whether a social service organization (e.g., a CBO) currently has the capacity to accept a new individual for a social care service (for assessment, or for a specific program or service). A response indicating available capacity does not guarantee eligibility or enrollment. See the SDOHCC Capacity Status value set for the allowed states.

Referral source

An organizational actor that initiates a referral to address an individual's social need (for example, a health care provider; or, in self-referral, the organization operating the community resource referral platform the individual uses to refer themselves). It operates the system actor that sends the referral and receives its status and results back.

Referral target

An organizational actor that receives a referral and has the resources to act on it by delivering — or, if it cannot, declining — the requested service or assessment (for example, a social service organization such as a CBO). It operates the system actor that receives the referral and returns its status and results.

Accountable community for health

A multisector, community-based partnerships that bring together health care, public health, social services, other local partners, and residents to address the unmet health and social needs of the individuals and communities they serve

Adapted from: California Accountable Communities for Health Initiative. (n.d.). The fundamentals. https://www.cachi.org/fundamentals

Backbone organization

Backbone organizations, critical to the work of multisector collaboratives and accountable communities for health, work with partner organizations and community members to translate a common agenda into tangible activities that partners and community members can implement to reach the goal set by the partners and community members. The Backbone Organizations help maintain overall strategic coherence and coordinates and manages the day-to-day operations and implementation of work, including stakeholder engagement, communications, data collection and analysis, and other responsibilities.

Adapted from: Breslau, J., Rasmussen, P. W., Qureshi, N., & Peet, E. D. (2023, November). Community care hubs: A promising model for health and social care coordination. Office of the Assistant Secretary for Planning and Evaluation & Administration for Community Living, U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf

Population Health Innovation Lab. (2023, June 14). Backbone organization. https://pophealthinnovationlab.org/data-walk/backbone-organization/

U.S. Department of Health and Human Services. (n.d.). HHS call to action: Addressing health-related social needs in communities across the nation. https://aspe.hhs.gov/sites/default/files/documents/54c9bfde7090c3d3f02a9fd924cb3e4a/hhs-call-to-action-health-related-social-needs.pdf

Community care hub

A type of backbone organization. Nonprofit organizations that provide a centralized administrative and operational interface between health care institutions and a network of CBOs that provide social services.

Breslau, J., Rasmussen, P. W., Qureshi, N., & Peet, E. D. (2023, November). Community care hubs: A promising model for health and social care coordination. Office of the Assistant Secretary for Planning and Evaluation & Administration for Community Living, U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/documents/81ff88859954186802b85137a61f412d/health-social-care-coordination.pdf

Social care network (SCN)

An outgrowth of the accountable health communities model, social care networks are coalitions of community-based organizations and health care providers connected through a common community resource referral platform to enable sustainable partnerships and efficient, measurable outcomes related to SDOH.

Adapted from: Galper, K., Miguel, C., LeJeune, K., Rung, J. M., Eddy, B., Kale, A., Schano, M., & Brignone, E. (2026). Design and early evaluation of a social care network's impact on health care costs. Health Affairs Scholar, 4(3), qxag051. https://doi.org/10.1093/haschl/qxag051

Community information exchange

A community-governed infrastructure that enables information to be effectively and responsibly shared among many organizations, using different, interoperable technologies, in support of holistic coordination of care and equitable systems change.

Kalinowski, A. G., Sorenson, P., & Johnson, B. H. (2025). Right-sizing technology for your community information exchange: A practical guide to connecting social service data systems [Report]. 211 San Diego/CIE. https://ciesandiego.org/wp-content/uploads/2025/10/CIE-Tech-Toolkit-Digital-Final-Part-1-2025.pdf

Sorenson, P., & Bloom, G. (2021, October). Tackling data dilemmas in social care coordination: Pursuing open and equitable infrastructure across a fragmented health and social service landscape [White paper]. St. Louis Regional Data Alliance at the University of Missouri–St. Louis; Data Across Sectors for Health. https://stldata.org/wp-content/uploads/2021/10/Social-Care-Data-Whitepaper-October-2021.pdf

Social service organization

An organization that works to address fundamental human needs in the community and promote social well-being.

Adapted from: Arons, A., Alban-Acuna, P., Simon, M., Whaley, J., Fossier, N., Simon, A., Rastogi, R., & Fichtenberg, C. (2025). Social service organizations report improvements in social services–health care integration in survey during California's Medicaid initiative ("CalAIM"). BMC Public Health, 25(1), 2234. https://doi.org/10.1186/s12889-025-23419-3

U.S. Department of Health & Human Services. (n.d.). Social services. https://www.hhs.gov/programs/social-services/index.html

Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems

Stanford Medicine. (2022, June 9). Connecting health care and social services. https://med.stanford.edu/news/insights/2022/06/connecting-health-care-and-social-services.html

Systems for Action. (n.d.). Linking medical homes to social service systems for Medicaid populations. https://systemsforaction.org/projects/linking-medical-homes-social-service-systems-medicaid-populations

Systems for Action. (n.d.). Webinar: Strengthening the carrying capacity of local health and social service agencies to absorb increased hospital/clinical referrals [Webinar]. https://systemsforaction.org/presentations/webinar-strengthening-carrying-capacity-local-health-and-social-service-agencies-0

Systems for Action. (n.d.). Webinar: Addressing social risk through medical home and social services connectivity and communication [Webinar]. https://systemsforaction.org/presentations/webinar-addressing-social-risk-through-medical-home-and-social-services-connectivity

Phillipse, R. J., Gadel, F., Millisor, J., & McClellan, J. (2026). The use of formal partnership agreements to align service delivery across health and social service systems. Human Service Organizations: Management, Leadership & Governance. https://doi.org/10.1080/23303131.2026.2619153

Social service program

A program with the mission to address fundamental human needs and improve the well-being of individuals, families, and/or communities.

U.S. Department of Health & Human Services. (n.d.). Social services. https://www.hhs.gov/programs/social-services/index.html

Systems for Action. (2025, May 7). Frequently asked questions. https://systemsforaction.org/frequently-asked-questions

Systems for Action. (n.d.). What organizations and activities are considered to be part of social service systems? https://systemsforaction.org/faq/what-organizations-and-activities-are-considered-be-part-social-service-systems

Health care organization

Health care organizations are organizations that provide health care services to individuals, including hospitals, nursing care facilities, home health agencies, and clinics. Health care organizations can be organized as governmental, not-for-profit, or commercial entities. If the health care entity is financially accountable to a primary government, it could be classified as a component unit of the government.

Becker. (n.d.). Health care organizations definition. https://www.becker.com/accounting-terms/health-care-organizations

Health program

A structured series of actions and strategies designed to maintain, promote, or improve the health of individuals, communities, or populations

Public health organization

An organization that works to create the conditions in which people can live healthy lives, including activities to prevent disease and injury and promote health for the population at large. They include governmental public health agencies working at local, state, and federal levels, as well as nongovernmental organizations that contribute to the performance of core public health functions. A defining feature of public health systems is their focus on actions designed to protect and improve health at a population level rather than purely at an individual level through the delivery of personal health services.

Adapted from: Systems for Action. (2025, May 7). Frequently asked questions. https://systemsforaction.org/frequently-asked-questions