Health Leads

Rebecca Onie.
United States
Initiative that promotes environmental and preventive health, integrating social and community services into the health care system to respond to unattended basic needs of patients and their families.
What solution does the innovation propose?

At the beginning, the solution was mainly focused on healthcare systems, assisting medical staff with tools and resources to carry out more holistic diagnostics and complementary referrals to social services. The logic was that, to improve health, it was necessary to address the diseases root causes, not the mitigation of symptoms. Today, the integral and preventive perspective on health has been enriched with a community-based focus.

Health Leads bridges and facilitates the exchange of resources and information between key actors: health, community and governmental institutions. Together, they are meant to identify and overcome specific systemic social, economic, and environmental barriers, which prevent from guaranteeing health, well-being and dignified living conditions for all. Health centers are a major gateway for families to access resources that will improve their quality of life and health. This requires a complete screening system encompassing more than physiological conditions and symptoms, as well as a well-connected and efficient referral system to community-based institutions. Recognizing the need to go beyond healthcare, the goal is to redesign the social safety network through community shared-power and decision-making, a sustainable community-based workforce, and open access and ownership of essential needs data.


GuideStar's Platinum Seal of Transparency (2019). Gleitsman Citizen Activist Award (2012). Skoll Award (2011). Rebecca Onie is an Ashoka Fellow (2008).

Impact evidence

  • Educational tools and resources freely available, elaborated on the basis of their experience designing and managing services in health centers.
  • Nearly 5,000 downloads of our Roadmap, Change Package, Screening Toolkit, webinars and White papers.  
  • Supported 3,000 health systems and physicians in CMS (Center for Medicare -Medicaid Services) pilots to integrate social needs into Medicaid payment models.
  • 60+ health systems participating in learning collaboratives.
  • 55,000+ patients served by over 25 organizations through our Reach technology
  • Rebecca Onie’s TED Talk video to “redefine what counts as healthcare” has been viewed over a million times.
  • Solid volunteer service which has served as a link between more than 15,000 patients and corresponding medical staff annually.
  • One of the first clinically validated studies of a social needs program (Health Leads at Massachusetts General Hospital) identified a significant link between meeting patients’ resource needs and improved health outcomes.
How does it work?

Health Leads has evolved in its more than 22 years of existence. Initially it set in motion a solid volunteer service which served as a link between patients, medical staff, and social services and resources. The collection of complementary information about an individual’s essential needs (i.e. needing access to food, assistance with utilities, transportation, housing concerns), started to gathered as part of patient medical records. Once codified and inside the system, this information was derived into social services, a care team or the Health Leads team. Soon after, Reach, a pioneer digital platform, compatible with the health centers systems to make the management and monitoring of referred patients more efficient, was created.

Nowadays the organization provides consulting services and learning collaboratives on the following focus areas:

  • Essential Health Resource Network. Design and build community-owned crisis-resilient governance and infrastructure that breaks down current silos and provides a complete, open view of available resources and the potential impact on health.
  • Essential Health Resource Workforce / Caregiver Sustainability. Ensure the families and communities who need it most have food, housing and other essential resources, while creating opportunities for displaced workers to earn an income.
  • Essential Health Resource Design & Analytics. Apply community-owned data to identify gaps, enable local collaboration and rebuild national and local systems so they work together seamlessly.
  • Essential Health Resource Learning & Thought Leadership. Share/connect front line workers with key insights, learnings, data and perspectives to speed broad adoption of equitable approaches and policies that address immediate resource needs and rebuild for the future.

Geographical scope

Where was initially developed
Boston Medical Center (United States).
Where has been implemented so far
More than 20 health centers in 19 cities of the United States such as the Johns Hopkins University Medical Center, Chicago Family Health or Massachusetts General Hospital.
Last updated: 
September 2020