Health Leads



Health Leads enables healthcare providers to write "prescriptions" for their patients’ basic needs, such as food, heat and gas. Trained volunteers staff desks at participating hospitals and clinics, and work with patients to connect them to local resources to address their needs. Since 2016, Health Leads has offered a utilization toolkit to help participants target eligible patients. The program is touted as a model that can help organizations participating in CMS’ Accountable Health Communities (AHC) and Comprehensive Primary Care Plus (CPC+) pilots.

Partner Organizations

  • Amgen
  • New Profit, Inc.
  • Skoll Foundation
  • Robert Wood Johnson Foundation
  • The Physicians Foundation

Target Population

Medicaid enrollees, Medicare beneficiaries and the uninsured with social service needs

Care Team

Volunteer care coordinators, nurse case manager, social worker, psychologist, pharmacist, nutritionist


1996 - present

Results/ Studies

Integrating Social Needs Into Health Care: A Twenty-Year Case Study Of Adaptation And Diffusion (Health Affairs, 2018)

Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management (JAMA Internal Medicine, 2017)

Addressing Basic Resource Needs to Improve Primary Care Quality: A Community Collaboration Programme (BMJ Quality & Safety, 2015)


Grant funded by numerous organizations


Program website

Resource library

News story: Health Leads Launches New Strategy to Advance Community-Led Health Aims (October 2018)