Social Needs Screening

Advancing Health Equity in Hillsborough County 

The Compass Program is a social needs screening and navigation program housed within the Office of Health Equity in the Community Health Division of the FLDOH-Hillsborough. The Compass Program promotes health equity in Hillsborough County by working on social determinants that influence poor health.

Some factors that can influence individual health include:

• Access to Care
• Food Insecurity
• Education
• Exposure to Violence
• Housing Stability / Safe Housing
• Employment / Job Security
• Transportation 

The Compass Program uses an innovative approach to address social needs that fall outside of the clinical encounter. Using a Social Needs Assessment Tool* (footnote with more information about the tool/citations), the Program screens clients receiving medical services at DOH-Hillsborough for health-related social needs. A Community Health Navigator then provides the client a tailored list of community resources that can help address their specific needs or will help the client connect to community partners to improve receipt of services.

Currently, the services offered by the Compass Program are only available to clients of DOH-Hillsborough’s Disease Control and WIC clinics. If you are a client of DOH-Hillsborough and would like to participate in the Program, please contact your DOH health services provider.

* Many of the questions used in this assessment were derived from the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs Screening Tool (AHC HRSN). The Compass Program acknowledges and extends our appreciation to the authors of the AHC HRSN questions for their permission to use these questions in the Compass Program’s Social Needs Assessment. For more information about the authors, please click here: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf