Stop Promising a Single ROI Number for HRSNs: Build an Evidence Model Instead
Health-related social needs can affect whether a care plan is practical, whether a patient can access follow-up, and whether clinical teams can sustain progress over time. Yet when organizations discuss the business case for addressing HRSNs, the conversation often collapses into one question: What is the ROI?
It is a reasonable question—but often an incomplete one.
A single ROI figure can obscure the reality that HRSN initiatives operate through multiple pathways. A program may improve the reach of screening, the consistency of documentation, the timeliness of outreach, the appropriateness of referrals, or the ability of teams to prioritize limited resources. Those operational changes may matter before a measurable utilization or total-cost-of-care change appears.
For healthcare executives, the more useful question is: What evidence would show that our Behavioral Health + HRSNs strategy is becoming more capable, equitable, and effective over time?
Social care work has more than one mechanism
The National Academies describes several ways healthcare organizations can engage with social care: awareness, adjustment, assistance, alignment, and advocacy. These approaches are related, but they are not interchangeable. Identifying a need in a screening workflow is different from adapting a care plan to that need. Referring someone to a community resource is different from building a durable partnership with that resource.
That distinction matters for measurement.
An organization that measures only completed screenings may conclude it has an HRSN strategy when it has actually measured an administrative step. Conversely, an organization that expects immediate savings from a referral program may discount meaningful progress in care coordination, access, or equitable follow-up because those gains do not map neatly to a single budget line.
The National Academies' social care framework is a useful reminder: the expected outcome should fit the intervention. Measurement needs to do the same.
Use a four-layer evidence model
Instead of asking one dashboard to prove everything, leaders can build an evidence model with four connected layers.
1. Visibility: Are relevant signals reaching the organization?
Start with what teams can see. This includes structured HRSN screening data, but it should not end there. Important context may exist in clinical documentation, care-management notes, discharge planning, and other operational records.
This is where Early Visibility can play a role. iBPM is designed to surface Behavioral Health + HRSNs signals from existing clinical documentation for clinical and organizational decision-makers. It does not diagnose patients; it can support teams in recognizing information that may warrant review between formal screenings or other established workflows.
Visibility measures may include the proportion of a priority population with actionable information available to an authorized team, the timeliness with which new signals are surfaced, and variation in visibility across service lines or demographic groups. The purpose is not to create a new risk score for its own sake. It is to understand whether teams have enough timely context to make sound decisions.
2. Operational response: Can teams act consistently?
Visibility without a response pathway can add noise rather than value. Organizations should therefore measure whether identified needs are reviewed, prioritized, assigned, and followed through according to locally defined workflows.
Useful questions include:
- Are high-priority cases reaching the appropriate care-management, behavioral health, or community-resource workflow?
- Is outreach capacity aligned with the population identified?
- Are teams documenting an action, a reason for no action, or a need for additional assessment?
- Where do referrals or handoffs stall?
These measures expose the operational constraints behind many underperforming programs. A low completion rate may reflect insufficient referral capacity, unclear ownership, disconnected technology, or a workflow that places too much burden on clinicians. It should not automatically be interpreted as patient disengagement.
3. Equity and experience: Who benefits from the workflow?
The CMS Framework for Health Equity emphasizes that health equity should be embedded in how organizations deliver and evaluate care—not treated as a separate reporting exercise. For Behavioral Health + HRSNs strategies, that means stratifying process and outcome measures where appropriate and lawful.
Leaders may examine whether some populations are less likely to have needs documented, receive timely follow-up, complete a connection to support, or remain engaged in care. Such differences do not establish why a disparity exists, but they can identify where further review is necessary.
This is also a governance issue. Measurement definitions, data-access policies, and human review processes should be explicit. AI-supported tools should be transparent about their intended use, monitored in practice, and kept under clinician and organizational oversight. Learn more about iBPM's approach to Responsible AI.
4. Clinical and financial outcomes: What changes over time—and what can reasonably be attributed?
Only after the first three layers are in place should organizations evaluate downstream outcomes such as potentially avoidable utilization, quality performance, continuity of care, or total cost of care.
That analysis should be appropriately cautious. Healthcare utilization is influenced by benefit design, access to community resources, disease burden, network performance, staffing, policy changes, and many other factors. A change in cost or utilization after launching an initiative is not, by itself, proof of causation.
A stronger approach compares outcomes against a defined baseline, uses clear cohorts, documents concurrent initiatives, and reviews both intended and unintended effects. For some programs, the most credible near-term evidence may be improved operational reach rather than savings. For others, a longer observation period may be needed.
Put financial discipline beside clinical humility
The goal is not to avoid financial accountability. It is to make accountability more credible.
A thoughtful business case can identify the resources required for data integration, workflow redesign, workforce capacity, community partnerships, and governance. It can also model plausible scenarios rather than presenting savings as guaranteed. This enables leaders to decide where investment is justified, what assumptions are being made, and what evidence would change the decision.
For organizations pursuing value-based care, this approach can turn HRSN measurement from a compliance exercise into a management capability. It creates a clearer line of sight from documentation to visibility, from visibility to action, and from action to outcomes that can be assessed responsibly.
iBPM's population health perspective and ROI resources are built around that discipline: earlier organizational intelligence, practical workflow support, and outcome measurement that does not overstate what technology alone can deliver.
Build the evidence before making the promise
Behavioral Health + HRSNs work deserves rigorous investment decisions. But rigor does not mean reducing a complex care strategy to one number on a slide.
It means defining the intervention, measuring whether it can be acted on, examining who benefits, and assessing downstream outcomes with appropriate controls and humility. Early Visibility may help organizations begin that work with more timely information already present in clinical documentation.
Explore how iBPM can support earlier, governed visibility for your population-health strategy: https://ibpm.ai/?utmsource=ibpm-website&utmmedium=blog&utm_campaign=ibpm-stop-promising-a-single-roi-number-for-h-2026-08-27
Sources
- National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. https://nap.nationalacademies.org/catalog/25467/integrating-social-care-into-the-delivery-of-health-care-moving
- Centers for Medicare & Medicaid Services. CMS Framework for Health Equity 2022–2032. https://www.cms.gov/files/document/cms-framework-health-equity.pdf