Epic Compass Rose is a module within the Epic electronic health record system that helps healthcare organizations screen patients for social needs, like housing instability or food insecurity, and then connect them to community resources directly from the patient’s chart. It’s designed to make social care coordination part of routine clinical work rather than a separate, paper-based process.
What Compass Rose Actually Does
At its core, Compass Rose bridges a gap that has frustrated healthcare teams for years: knowing a patient has a social need but having no efficient way to do anything about it. The module integrates screening tools for nonclinical factors that affect health into the patient’s medical record, creating a single profile that captures both clinical and social information. When a patient flags a need on a screening questionnaire, Compass Rose automatically generates an episode in their chart, triggering a workflow that care teams can act on.
The domains it covers are broad, spanning transportation, housing status, food insecurity, financial strain, utilities, stress, social isolation, education, employment, and interpersonal violence. These categories reflect what public health researchers call social determinants of health (sometimes shortened to SDOH), the everyday conditions outside of a clinic that shape whether someone stays healthy or gets sicker.
How Screening and Referrals Work
The typical workflow starts with a patient completing a standardized screening, often during a visit or through outreach. If the patient indicates at least one social risk factor, Compass Rose creates a trackable episode in their record. From there, a care team member can review the flagged needs and send referrals to community-based organizations, all without leaving Epic.
This is where the “closed-loop referral” concept comes in. In the traditional model, a clinician might hand a patient a printed list of food banks or housing programs and hope for the best. Nobody knew whether the patient followed through or whether the organization had capacity to help. Compass Rose changes that by connecting to external platforms like Findhelp, where community organizations can log in and update the status of a referral. Staff on both sides, the clinical team and the community organization, can see which services were requested and which were actually provided.
Research published in The Annals of Family Medicine found that Compass Rose was adaptable across a variety of clinical settings, easy for staff to use, and effective at closing the referral feedback loop between community organizations and clinical teams. Houston Methodist, for example, trained clinicians to send referrals through Compass Rose to partner organizations that then logged into Epic’s Healthy Planet Link to manage their end of the process. The entire workflow stays within Epic, so clinicians don’t need to navigate unfamiliar interfaces or track referrals manually.
Where It Fits in Population Health
Compass Rose is part of Epic’s broader population health toolkit, which helps health systems manage care for large groups of patients rather than one visit at a time. That toolkit includes features for risk stratification (sorting patients by how much support they need), closing care gaps, and tracking contract performance metrics. Compass Rose adds the social care layer to this picture, letting organizations identify patterns in unmet social needs across their patient population and target resources accordingly.
For health systems managing value-based contracts, where they’re financially responsible for patient outcomes rather than just billing per visit, addressing social barriers is increasingly important. A patient with uncontrolled diabetes who also lacks reliable transportation to pick up insulin is a very different challenge than one who simply needs a medication adjustment. Compass Rose gives organizations a way to document, track, and act on those non-medical factors at scale.
Who Uses It
Compass Rose isn’t limited to a single role. Care managers, social workers, community health workers, and clinicians all interact with the module depending on how a health system configures its workflows. OCHIN, a health IT network that serves community health centers, has built an entire portfolio around Compass Rose to help safety-net providers integrate social needs screening into routine care. Larger academic medical centers and hospital systems use it too, often customizing the enrollment criteria, outreach methods, and referral partners to match their patient populations.
The flexibility is notable. Organizations can standardize which screening tools they use, define which risk factors trigger a Compass Rose episode, and choose which community resource directories to connect with. This means two health systems running Compass Rose might have quite different workflows, but the underlying structure of screen, flag, refer, and track remains the same.
Why It Matters for Patients
From a patient’s perspective, Compass Rose is mostly invisible. You might notice it as a few extra questions during a doctor’s visit asking whether you’ve had trouble paying for food, felt unsafe at home, or struggled to get to appointments. If you answer yes, someone from the care team may follow up with specific resources rather than a generic suggestion to “look into it.” The referral goes directly to an organization equipped to help, and your care team can see whether that connection was made.
The practical difference is accountability. Instead of social needs being noted once and forgotten, they become a tracked part of the care plan. If a referral to a housing assistance program doesn’t go through, the care team sees that and can try a different approach. This closed-loop model is still relatively new in healthcare, and not every organization has fully implemented it, but it represents a meaningful shift from treating social needs as someone else’s problem.